{"id":5523,"date":"2025-09-11T15:42:26","date_gmt":"2025-09-11T13:42:26","guid":{"rendered":"https:\/\/insbrok.com\/cuestionario-de-salud-de-asisa\/"},"modified":"2025-09-11T15:42:26","modified_gmt":"2025-09-11T13:42:26","slug":"cuestionario-de-salud-de-asisa","status":"publish","type":"page","link":"https:\/\/insbrok.com\/es\/cuestionario-de-salud-de-asisa\/","title":{"rendered":"Cuestionario de Salud de Asisa"},"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 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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_68' style='display:none'><div id='gf_68' 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_68'  action='\/es\/wp-json\/wp\/v2\/pages\/5523#gf_68' data-formid='68' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_page_68_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_68' class='gform_fields top_label form_sublabel_above description_below validation_below'><fieldset id=\"field_68_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_above 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=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Tomador del seguro<\/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_68_1'>\n                            \n                            <span id='input_68_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_68_1_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                    <input type='text' name='input_1.3' id='input_68_1_3' value='no'   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_68_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_68_1_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                            <input type='text' name='input_1.6' id='input_68_1_6' value='ph'   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_68_270\" 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_below field_validation_below gfield_visibility_visible\"  >As part of Asisa's insurance requirements, all applicants must complete this health questionnaire before coverage can be processed.<\/div><fieldset id=\"field_68_2\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required 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' >Nombre<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_68_2'>\n                            \n                            <span id='input_68_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_68_2_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                    <input type='text' name='input_2.3' id='input_68_2_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_68_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_68_2_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                            <input type='text' name='input_2.6' id='input_68_2_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_68_41\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_41'>Fecha de nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_41' id='input_68_41' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_68_41_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_68_41_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_68_41' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_68_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_3'>NIF, NIE, o pasaporte<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_68_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_68_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_2col gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >G\u00e9nero<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_6'>\n\t\t\t<div class='gchoice gchoice_68_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='MALE'  id='choice_68_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_6_0' id='label_68_6_0' class='gform-field-label gform-field-label--type-inline'>HOMBRE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='FEMALE'  id='choice_68_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_6_1' id='label_68_6_1' class='gform-field-label gform-field-label--type-inline'>MUJER<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_4\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_4'>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_4' id='input_68_4' type='number' step='any' min='50' max='240' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_68_4\" \/><div class='gfield_description instruction ' id='gfield_instruction_68_4'>Por favor, escribe un n\u00famero entre <strong>50<\/strong> y <strong>240<\/strong>.<\/div><\/div><\/div><div id=\"field_68_5\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_5'>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_5' id='input_68_5' type='number' step='any' min='2' max='250' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_68_5\" \/><div class='gfield_description instruction ' id='gfield_instruction_68_5'>Por favor, escribe un n\u00famero entre <strong>2<\/strong> y <strong>250<\/strong>.<\/div><\/div><\/div><div id=\"field_68_47\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_above 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=\"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_68_47'>Number of Individuals<\/label><div class='ginput_container ginput_container_number'><input name='input_47' id='input_68_47' type='number' step='any' min='1' max='7' value='1' class='small'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_68_47\" \/><div class='gfield_description instruction ' id='gfield_instruction_68_47'>Por favor, escribe un n\u00famero entre <strong>1<\/strong> y <strong>7<\/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_68_9' 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_68_2' class='gform_page' data-js='page-field-id-9' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_68_2' class='gform_fields top_label form_sublabel_above description_below validation_below'><fieldset id=\"field_68_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfHa estado hospitalizado en un centro sanitario en los \u00faltimos 10 a\u00f1os, o tiene alguna hospitalizaci\u00f3n programada?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_7'>\n\t\t\t<div class='gchoice gchoice_68_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='YES'  id='choice_68_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_7_0' id='label_68_7_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='NO'  id='choice_68_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_7_1' id='label_68_7_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_27\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_27'>Por favor, indique el motivo y la(s) fecha(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_68_27' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. \u00bfSe ha realizado alguna intervenci\u00f3n quir\u00fargica, o tiene prevista alguna intervenci\u00f3n quir\u00fargica?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_8'>\n\t\t\t<div class='gchoice gchoice_68_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='YES'  id='choice_68_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_8_0' id='label_68_8_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='NO'  id='choice_68_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_8_1' id='label_68_8_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_28\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_28'>Por favor, indique el motivo y la(s) fecha(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_68_28' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. \u00bfPadece o ha padecido alg\u00fan tumor o c\u00e1ncer?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_10'>\n\t\t\t<div class='gchoice gchoice_68_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='YES'  id='choice_68_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_10_0' id='label_68_10_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='NO'  id='choice_68_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_10_1' id='label_68_10_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_29\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_29'>Por favor, especifique cu\u00e1l y la(s) fecha(s) de diagn\u00f3stico<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_68_29' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. \u00bfPadece o ha padecido alg\u00fan s\u00edntoma, dolor o trastorno de manera persistente, regular o recurrente, o se encuentra bajo supervisi\u00f3n o control m\u00e9dico por alguna raz\u00f3n?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_11'>\n\t\t\t<div class='gchoice gchoice_68_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='YES'  id='choice_68_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_11_0' id='label_68_11_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='NO'  id='choice_68_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_11_1' id='label_68_11_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_30\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_30'>Por favor, indique el motivo y la(s) fecha(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_68_30' class='textarea large'   maxlength='155'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_68_13\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">5. \u00bfTiene o ha tenido alguno de los siguientes tipos de condici\u00f3n, lesi\u00f3n o trastorno?<\/h3><\/div><fieldset id=\"field_68_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.1 Card\u00edacas, vasculares, pulmonares o respiratorias (ej.: hipertensi\u00f3n, arritmias, insuficiencia card\u00edaca o circulatoria, varices, asma, enfisema, trombosis, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_14'>\n\t\t\t<div class='gchoice gchoice_68_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='YES'  id='choice_68_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_14_0' id='label_68_14_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='NO'  id='choice_68_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_14_1' id='label_68_14_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.2 Metab\u00f3licas (del sistema endocrino) o del sistema digestivo (ej.: del h\u00edgado o p\u00e1ncreas, \u00falcera g\u00e1strica o duodenal, hernias, diabetes, enfermedad tiroidea, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_15'>\n\t\t\t<div class='gchoice gchoice_68_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='YES'  id='choice_68_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_15_0' id='label_68_15_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='NO'  id='choice_68_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_15_1' id='label_68_15_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.3 Reum\u00e1ticas, \u00f3seas o musculares (ej.: artritis, artrosis, escoliosis, hernia discal, fibromialgia, lupus, esclerodermia, trastorno muscular, secuelas de traumatismos, psoriasis, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_16'>\n\t\t\t<div class='gchoice gchoice_68_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='YES'  id='choice_68_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_16_0' id='label_68_16_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='NO'  id='choice_68_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_16_1' id='label_68_16_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.4 Del sistema nervioso, de los ojos o de los o\u00eddos (ej.: migra\u00f1as, epilepsia, enfermedad de Parkinson, par\u00e1lisis, enfermedad de Alzheimer, glaucoma, degeneraci\u00f3n macular, p\u00e9rdida de visi\u00f3n, TDAH, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_17'>\n\t\t\t<div class='gchoice gchoice_68_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='YES'  id='choice_68_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_17_0' id='label_68_17_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='NO'  id='choice_68_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_17_1' id='label_68_17_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.5 Hematol\u00f3gicas o de coagulaci\u00f3n (ej.: tromboembolismo, anemia, hemofilia, leucemia, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_18'>\n\t\t\t<div class='gchoice gchoice_68_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='YES'  id='choice_68_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_18_0' id='label_68_18_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='NO'  id='choice_68_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_18_1' id='label_68_18_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.6 Del ri\u00f1\u00f3n, del aparato urol\u00f3gico y genital, o ginecol\u00f3gicas (ej.: insuficiencia renal, problemas de pr\u00f3stata, c\u00f3lico nefr\u00edtico, de transmisi\u00f3n sexual, ginecol\u00f3gicas - mama, \u00fatero, ovarios, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_19'>\n\t\t\t<div class='gchoice gchoice_68_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='YES'  id='choice_68_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_19_0' id='label_68_19_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='NO'  id='choice_68_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_19_1' id='label_68_19_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.7 Psiqui\u00e1tricas (ej.: anorexia, bulimia, depresi\u00f3n, ansiedad, psicosis, esquizofrenia, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_20'>\n\t\t\t<div class='gchoice gchoice_68_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='YES'  id='choice_68_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_20_0' id='label_68_20_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='NO'  id='choice_68_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_20_1' id='label_68_20_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.8 Enfermedades infecciosas (ej.: hepatitis, COVID-19, tuberculosis, infecciones parasitarias, septicemia, enfermedades tropicales, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_21'>\n\t\t\t<div class='gchoice gchoice_68_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='YES'  id='choice_68_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_21_0' id='label_68_21_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='NO'  id='choice_68_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_21_1' id='label_68_21_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_31\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_31'>Por favor, indique cu\u00e1l:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_68_31' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_68_45\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Other<\/h3><\/div><fieldset id=\"field_68_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. \u00bfEst\u00e1 tomando alg\u00fan medicamento?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_23'>\n\t\t\t<div class='gchoice gchoice_68_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='YES'  id='choice_68_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_23_0' id='label_68_23_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='NO'  id='choice_68_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_23_1' id='label_68_23_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_32\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_32'>Especifique cu\u00e1l, dosis y frecuencia (r\u00e9gimen):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_68_32' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. \u00bfConsume alcohol, drogas o tabaco?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_24'>\n\t\t\t<div class='gchoice gchoice_68_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='YES'  id='choice_68_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_24_0' id='label_68_24_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='NO'  id='choice_68_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_24_1' id='label_68_24_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_33\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_33'>Indique el tipo, cantidad consumida y frecuencia:<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_68_33' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >8. \u00bfTiene lesiones o secuelas de alguna enfermedad, trastorno cong\u00e9nito o hereditario, malformaciones o un accidente?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_25'>\n\t\t\t<div class='gchoice gchoice_68_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='YES'  id='choice_68_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_25_0' id='label_68_25_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='NO'  id='choice_68_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_25_1' id='label_68_25_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_34\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_34'>Por favor, indique cu\u00e1l y proporcione un informe m\u00e9dico:<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_68_34' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >9. \u00bfTiene reconocida alguna discapacidad o diversidad funcional, o est\u00e1 siendo evaluado\/a para alguna?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_26'>\n\t\t\t<div class='gchoice gchoice_68_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='YES'  id='choice_68_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_26_0' id='label_68_26_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='NO'  id='choice_68_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_26_1' id='label_68_26_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_35\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_35'>Por favor, indique cu\u00e1l y proporcione un informe m\u00e9dico:<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_68_35' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_68_46' 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_68_46' 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_68_3' class='gform_page' data-js='page-field-id-46' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_68_3' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_68_264\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Individual 2<\/h3><\/div><fieldset id=\"field_68_48\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required 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' >Name<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_68_48'>\n                            \n                            <span id='input_68_48_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_68_48_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                    <input type='text' name='input_48.3' id='input_68_48_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_68_48_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_68_48_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                            <input type='text' name='input_48.6' id='input_68_48_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_68_49\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_49'>Date of birth<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_49' id='input_68_49' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_68_49_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_68_49_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_68_49' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_68_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_50'>NIF, NIE, or Passport<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_68_50' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_68_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_2col gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_51'>\n\t\t\t<div class='gchoice gchoice_68_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='MALE'  id='choice_68_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_51_0' id='label_68_51_0' class='gform-field-label gform-field-label--type-inline'>MALE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='FEMALE'  id='choice_68_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_51_1' id='label_68_51_1' class='gform-field-label gform-field-label--type-inline'>FEMALE<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_52\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_52'>Height in centimetres<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_52' id='input_68_52' type='number' step='any' min='50' max='240' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_68_52\" \/><div class='gfield_description instruction ' id='gfield_instruction_68_52'>Por favor, escribe un n\u00famero entre <strong>50<\/strong> y <strong>240<\/strong>.<\/div><\/div><\/div><div id=\"field_68_53\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_53'>Weight in kilograms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_53' id='input_68_53' type='number' step='any' min='2' max='250' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_68_53\" \/><div class='gfield_description instruction ' id='gfield_instruction_68_53'>Por favor, escribe un n\u00famero entre <strong>2<\/strong> y <strong>250<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_68_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1.Have you been admitted to a health centre in the last 10 years, or do you have any admissions scheduled?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_56'>\n\t\t\t<div class='gchoice gchoice_68_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='YES'  id='choice_68_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_56_0' id='label_68_56_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='NO'  id='choice_68_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_56_1' id='label_68_56_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_57\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_57'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_57' id='input_68_57' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_58\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2.Have you undergone any surgery, or are you scheduled to undergo any surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_58'>\n\t\t\t<div class='gchoice gchoice_68_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='YES'  id='choice_68_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_58_0' id='label_68_58_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='NO'  id='choice_68_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_58_1' id='label_68_58_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_59\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_59'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_59' id='input_68_59' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. Do you have or have you had any tumours or cancer?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_60'>\n\t\t\t<div class='gchoice gchoice_68_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='YES'  id='choice_68_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_60_0' id='label_68_60_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='NO'  id='choice_68_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_60_1' id='label_68_60_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_61\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_61'>Please specify which and the date(s) of diagnosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_61' id='input_68_61' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Have you or have you had any symptoms, pain or disorder persistently, regularly or recurringly, or are you under medical supervision or monitoring for any reason?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_62'>\n\t\t\t<div class='gchoice gchoice_68_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='YES'  id='choice_68_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_62_0' id='label_68_62_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='NO'  id='choice_68_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_62_1' id='label_68_62_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_63\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_63'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_63' id='input_68_63' class='textarea large'   maxlength='155'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_68_64\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Have you or have you had any of the following types of condition, injury or disorder?<\/h3><\/div><fieldset id=\"field_68_65\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.1 Cardiac, vascular, pulmonary or respiratory (e. g.: hypertension, arrhythmias, heart or circulatory failure, varices, asthma, emphysema, thrombosis, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_65'>\n\t\t\t<div class='gchoice gchoice_68_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='YES'  id='choice_68_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_65_0' id='label_68_65_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='NO'  id='choice_68_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_65_1' id='label_68_65_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.2 Metabolic (of the endocrine system) or of the digestive system (e. g.: of the liver or pancreas, gastric or duodenal ulcer, hernias, diabetes, thyroid disease, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_66'>\n\t\t\t<div class='gchoice gchoice_68_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='YES'  id='choice_68_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_66_0' id='label_68_66_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='NO'  id='choice_68_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_66_1' id='label_68_66_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_67\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.3 Rheumatic, bone or muscular (e. g.: arthritis, osteoarthritis, scoliosis, slipped disc, fibromyalgia, lupus, scleroderma, muscle disorder, trauma sequelae, psoriasis, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_67'>\n\t\t\t<div class='gchoice gchoice_68_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='YES'  id='choice_68_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_67_0' id='label_68_67_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='NO'  id='choice_68_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_67_1' id='label_68_67_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_68\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.4 Of the nervous system, of the eyes or of the ears (e. g.: migraines, epilepsy, Parkinson&#039;s disease, paralysis, Alzheimer&#039;s disease, glaucoma, macular degeneration, vision loss, ADHD, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_68'>\n\t\t\t<div class='gchoice gchoice_68_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='YES'  id='choice_68_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_68_0' id='label_68_68_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='NO'  id='choice_68_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_68_1' id='label_68_68_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_69\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.5 Haematological or clotting (e. g.: thromboembolism, anaemia, haemophilia, leukaemia, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_69'>\n\t\t\t<div class='gchoice gchoice_68_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='YES'  id='choice_68_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_69_0' id='label_68_69_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='NO'  id='choice_68_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_69_1' id='label_68_69_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_70\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.6 Of the kidney, urological and genital tract, or gynaecological (e. g.: kidney failure, prostate problems, renal colic, sexually transmitted, gynaecological - breast, uterus, ovaries, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_70'>\n\t\t\t<div class='gchoice gchoice_68_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='YES'  id='choice_68_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_70_0' id='label_68_70_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='NO'  id='choice_68_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_70_1' id='label_68_70_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.7 Psychiatric (e. g.: anorexia, bulimia, depression, anxiety, psychosis, schizophrenia, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_71'>\n\t\t\t<div class='gchoice gchoice_68_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='YES'  id='choice_68_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_71_0' id='label_68_71_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='NO'  id='choice_68_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_71_1' id='label_68_71_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.8 Infectious diseases (e. g.: hepatitis, COVID-19, tuberculosis, parasitic infections, septicaemia, tropical diseases, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_72'>\n\t\t\t<div class='gchoice gchoice_68_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='YES'  id='choice_68_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_72_0' id='label_68_72_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='NO'  id='choice_68_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_72_1' id='label_68_72_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_73\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_73'>Please indicate which:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_73' id='input_68_73' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_68_74\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Other<\/h3><\/div><fieldset id=\"field_68_75\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Do you take any medication?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_75'>\n\t\t\t<div class='gchoice gchoice_68_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='YES'  id='choice_68_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_75_0' id='label_68_75_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='NO'  id='choice_68_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_75_1' id='label_68_75_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_76\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_76'>Indicate which, dose and frequency (regimen):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_76' id='input_68_76' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_77\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Do you consume alcohol or drugs or do you smoke?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_77'>\n\t\t\t<div class='gchoice gchoice_68_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='YES'  id='choice_68_77_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_77_0' id='label_68_77_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='NO'  id='choice_68_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_77_1' id='label_68_77_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_78\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_78'>Indicate the type, amount consumed and frequency:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_78' id='input_68_78' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_79\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >8. Do you have lesions or sequelae from a disease, congenital or hereditary disorder, malformations or an accident?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_79'>\n\t\t\t<div class='gchoice gchoice_68_79_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='YES'  id='choice_68_79_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_79_0' id='label_68_79_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_79_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='NO'  id='choice_68_79_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_79_1' id='label_68_79_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_80\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_80'>Please indicate which and provide a medical report:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_80' id='input_68_80' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >9. Do you have any recognised handicap or disability, or are you in the process of being assessed for any?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_81'>\n\t\t\t<div class='gchoice gchoice_68_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='YES'  id='choice_68_81_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_81_0' id='label_68_81_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='NO'  id='choice_68_81_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_81_1' id='label_68_81_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_82\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_82'>Please indicate which and provide a medical report:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_82' id='input_68_82' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_68_83' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_68_83' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_68_4' class='gform_page' data-js='page-field-id-83' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_68_4' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_68_265\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Individual 3<\/h3><\/div><fieldset id=\"field_68_84\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required 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' >Name<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_68_84'>\n                            \n                            <span id='input_68_84_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_68_84_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                    <input type='text' name='input_84.3' id='input_68_84_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_68_84_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_68_84_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                            <input type='text' name='input_84.6' id='input_68_84_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_68_85\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_85'>Date of birth<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_85' id='input_68_85' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_68_85_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_68_85_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_68_85' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_68_86\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_86'>NIF, NIE, or Passport<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_68_86' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_68_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_2col gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_87'>\n\t\t\t<div class='gchoice gchoice_68_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='MALE'  id='choice_68_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_87_0' id='label_68_87_0' class='gform-field-label gform-field-label--type-inline'>MALE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='FEMALE'  id='choice_68_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_87_1' id='label_68_87_1' class='gform-field-label gform-field-label--type-inline'>FEMALE<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_88\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_88'>Height in centimetres<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_88' id='input_68_88' type='number' step='any' min='50' max='240' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_68_88\" \/><div class='gfield_description instruction ' id='gfield_instruction_68_88'>Por favor, escribe un n\u00famero entre <strong>50<\/strong> y <strong>240<\/strong>.<\/div><\/div><\/div><div id=\"field_68_89\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_89'>Weight in kilograms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_89' id='input_68_89' type='number' step='any' min='2' max='250' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_68_89\" \/><div class='gfield_description instruction ' id='gfield_instruction_68_89'>Por favor, escribe un n\u00famero entre <strong>2<\/strong> y <strong>250<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_68_92\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1.Have you been admitted to a health centre in the last 10 years, or do you have any admissions scheduled?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_92'>\n\t\t\t<div class='gchoice gchoice_68_92_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='YES'  id='choice_68_92_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_92_0' id='label_68_92_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_92_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='NO'  id='choice_68_92_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_92_1' id='label_68_92_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_93\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_93'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_93' id='input_68_93' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_94\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2.Have you undergone any surgery, or are you scheduled to undergo any surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_94'>\n\t\t\t<div class='gchoice gchoice_68_94_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='YES'  id='choice_68_94_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_94_0' id='label_68_94_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_94_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='NO'  id='choice_68_94_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_94_1' id='label_68_94_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_95\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_95'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_95' id='input_68_95' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_96\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. Do you have or have you had any tumours or cancer?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_96'>\n\t\t\t<div class='gchoice gchoice_68_96_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='YES'  id='choice_68_96_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_96_0' id='label_68_96_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_96_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='NO'  id='choice_68_96_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_96_1' id='label_68_96_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_97\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_97'>Please specify which and the date(s) of diagnosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_97' id='input_68_97' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_98\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Have you or have you had any symptoms, pain or disorder persistently, regularly or recurringly, or are you under medical supervision or monitoring for any reason?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_98'>\n\t\t\t<div class='gchoice gchoice_68_98_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='YES'  id='choice_68_98_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_98_0' id='label_68_98_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_98_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='NO'  id='choice_68_98_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_98_1' id='label_68_98_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_99\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_99'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_99' id='input_68_99' class='textarea large'   maxlength='155'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_68_100\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Have you or have you had any of the following types of condition, injury or disorder?<\/h3><\/div><fieldset id=\"field_68_101\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.1 Cardiac, vascular, pulmonary or respiratory (e. g.: hypertension, arrhythmias, heart or circulatory failure, varices, asthma, emphysema, thrombosis, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_101'>\n\t\t\t<div class='gchoice gchoice_68_101_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='YES'  id='choice_68_101_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_101_0' id='label_68_101_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_101_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='NO'  id='choice_68_101_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_101_1' id='label_68_101_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_102\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.2 Metabolic (of the endocrine system) or of the digestive system (e. g.: of the liver or pancreas, gastric or duodenal ulcer, hernias, diabetes, thyroid disease, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_102'>\n\t\t\t<div class='gchoice gchoice_68_102_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='YES'  id='choice_68_102_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_102_0' id='label_68_102_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_102_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='NO'  id='choice_68_102_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_102_1' id='label_68_102_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_103\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.3 Rheumatic, bone or muscular (e. g.: arthritis, osteoarthritis, scoliosis, slipped disc, fibromyalgia, lupus, scleroderma, muscle disorder, trauma sequelae, psoriasis, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_103'>\n\t\t\t<div class='gchoice gchoice_68_103_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='YES'  id='choice_68_103_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_103_0' id='label_68_103_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_103_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='NO'  id='choice_68_103_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_103_1' id='label_68_103_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_104\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.4 Of the nervous system, of the eyes or of the ears (e. g.: migraines, epilepsy, Parkinson&#039;s disease, paralysis, Alzheimer&#039;s disease, glaucoma, macular degeneration, vision loss, ADHD, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_104'>\n\t\t\t<div class='gchoice gchoice_68_104_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='YES'  id='choice_68_104_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_104_0' id='label_68_104_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_104_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='NO'  id='choice_68_104_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_104_1' id='label_68_104_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_105\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.5 Haematological or clotting (e. g.: thromboembolism, anaemia, haemophilia, leukaemia, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_105'>\n\t\t\t<div class='gchoice gchoice_68_105_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='YES'  id='choice_68_105_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_105_0' id='label_68_105_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_105_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='NO'  id='choice_68_105_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_105_1' id='label_68_105_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_106\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.6 Of the kidney, urological and genital tract, or gynaecological (e. g.: kidney failure, prostate problems, renal colic, sexually transmitted, gynaecological - breast, uterus, ovaries, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_106'>\n\t\t\t<div class='gchoice gchoice_68_106_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='YES'  id='choice_68_106_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_106_0' id='label_68_106_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_106_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='NO'  id='choice_68_106_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_106_1' id='label_68_106_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_107\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.7 Psychiatric (e. g.: anorexia, bulimia, depression, anxiety, psychosis, schizophrenia, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_107'>\n\t\t\t<div class='gchoice gchoice_68_107_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='YES'  id='choice_68_107_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_107_0' id='label_68_107_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_107_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='NO'  id='choice_68_107_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_107_1' id='label_68_107_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_108\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.8 Infectious diseases (e. g.: hepatitis, COVID-19, tuberculosis, parasitic infections, septicaemia, tropical diseases, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_108'>\n\t\t\t<div class='gchoice gchoice_68_108_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='YES'  id='choice_68_108_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_108_0' id='label_68_108_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_108_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='NO'  id='choice_68_108_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_108_1' id='label_68_108_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_109\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_109'>Please indicate which:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_109' id='input_68_109' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_68_110\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Other<\/h3><\/div><fieldset id=\"field_68_111\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Do you take any medication?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_111'>\n\t\t\t<div class='gchoice gchoice_68_111_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='YES'  id='choice_68_111_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_111_0' id='label_68_111_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_111_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='NO'  id='choice_68_111_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_111_1' id='label_68_111_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_112\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_112'>Indicate which, dose and frequency (regimen):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_112' id='input_68_112' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_113\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Do you consume alcohol or drugs or do you smoke?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_113'>\n\t\t\t<div class='gchoice gchoice_68_113_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='YES'  id='choice_68_113_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_113_0' id='label_68_113_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_113_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='NO'  id='choice_68_113_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_113_1' id='label_68_113_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_114\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_114'>Indicate the type, amount consumed and frequency:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_114' id='input_68_114' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_115\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >8. Do you have lesions or sequelae from a disease, congenital or hereditary disorder, malformations or an accident?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_115'>\n\t\t\t<div class='gchoice gchoice_68_115_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='YES'  id='choice_68_115_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_115_0' id='label_68_115_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_115_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='NO'  id='choice_68_115_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_115_1' id='label_68_115_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_116\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_116'>Please indicate which and provide a medical report:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_116' id='input_68_116' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_117\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >9. Do you have any recognised handicap or disability, or are you in the process of being assessed for any?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_117'>\n\t\t\t<div class='gchoice gchoice_68_117_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_117' type='radio' value='YES'  id='choice_68_117_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_117_0' id='label_68_117_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_117_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_117' type='radio' value='NO'  id='choice_68_117_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_117_1' id='label_68_117_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_118\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_118'>Please indicate which and provide a medical report:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_118' id='input_68_118' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_68_119' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_68_119' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_68_5' class='gform_page' data-js='page-field-id-119' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_68_5' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_68_266\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Individual 4<\/h3><\/div><fieldset id=\"field_68_120\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required 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' >Name<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_68_120'>\n                            \n                            <span id='input_68_120_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_68_120_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                    <input type='text' name='input_120.3' id='input_68_120_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_68_120_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_68_120_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                            <input type='text' name='input_120.6' id='input_68_120_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_68_121\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_121'>Date of birth<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_121' id='input_68_121' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_68_121_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_68_121_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_68_121' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_68_122\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_122'>NIF, NIE, or Passport<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_122' id='input_68_122' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_68_123\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_2col gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_123'>\n\t\t\t<div class='gchoice gchoice_68_123_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='MALE'  id='choice_68_123_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_123_0' id='label_68_123_0' class='gform-field-label gform-field-label--type-inline'>MALE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_123_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='FEMALE'  id='choice_68_123_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_123_1' id='label_68_123_1' class='gform-field-label gform-field-label--type-inline'>FEMALE<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_124\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_124'>Height in centimetres<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_124' id='input_68_124' type='number' step='any' min='50' max='240' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_68_124\" \/><div class='gfield_description instruction ' id='gfield_instruction_68_124'>Por favor, escribe un n\u00famero entre <strong>50<\/strong> y <strong>240<\/strong>.<\/div><\/div><\/div><div id=\"field_68_125\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_125'>Weight in kilograms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_125' id='input_68_125' type='number' step='any' min='2' max='250' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_68_125\" \/><div class='gfield_description instruction ' id='gfield_instruction_68_125'>Por favor, escribe un n\u00famero entre <strong>2<\/strong> y <strong>250<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_68_128\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1.Have you been admitted to a health centre in the last 10 years, or do you have any admissions scheduled?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_128'>\n\t\t\t<div class='gchoice gchoice_68_128_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='YES'  id='choice_68_128_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_128_0' id='label_68_128_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_128_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='NO'  id='choice_68_128_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_128_1' id='label_68_128_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_129\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_129'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_129' id='input_68_129' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_130\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2.Have you undergone any surgery, or are you scheduled to undergo any surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_130'>\n\t\t\t<div class='gchoice gchoice_68_130_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='YES'  id='choice_68_130_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_130_0' id='label_68_130_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_130_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='NO'  id='choice_68_130_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_130_1' id='label_68_130_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_131\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_131'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_131' id='input_68_131' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_132\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. Do you have or have you had any tumours or cancer?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_132'>\n\t\t\t<div class='gchoice gchoice_68_132_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_132' type='radio' value='YES'  id='choice_68_132_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_132_0' id='label_68_132_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_132_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_132' type='radio' value='NO'  id='choice_68_132_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_132_1' id='label_68_132_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_133\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_133'>Please specify which and the date(s) of diagnosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_133' id='input_68_133' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_134\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Have you or have you had any symptoms, pain or disorder persistently, regularly or recurringly, or are you under medical supervision or monitoring for any reason?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_134'>\n\t\t\t<div class='gchoice gchoice_68_134_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='YES'  id='choice_68_134_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_134_0' id='label_68_134_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_134_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='NO'  id='choice_68_134_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_134_1' id='label_68_134_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_135\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_135'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_135' id='input_68_135' class='textarea large'   maxlength='155'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_68_136\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Have you or have you had any of the following types of condition, injury or disorder?<\/h3><\/div><fieldset id=\"field_68_137\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.1 Cardiac, vascular, pulmonary or respiratory (e. g.: hypertension, arrhythmias, heart or circulatory failure, varices, asthma, emphysema, thrombosis, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_137'>\n\t\t\t<div class='gchoice gchoice_68_137_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='YES'  id='choice_68_137_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_137_0' id='label_68_137_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_137_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='NO'  id='choice_68_137_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_137_1' id='label_68_137_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_138\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.2 Metabolic (of the endocrine system) or of the digestive system (e. g.: of the liver or pancreas, gastric or duodenal ulcer, hernias, diabetes, thyroid disease, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_138'>\n\t\t\t<div class='gchoice gchoice_68_138_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_138' type='radio' value='YES'  id='choice_68_138_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_138_0' id='label_68_138_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_138_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_138' type='radio' value='NO'  id='choice_68_138_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_138_1' id='label_68_138_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_139\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.3 Rheumatic, bone or muscular (e. g.: arthritis, osteoarthritis, scoliosis, slipped disc, fibromyalgia, lupus, scleroderma, muscle disorder, trauma sequelae, psoriasis, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_139'>\n\t\t\t<div class='gchoice gchoice_68_139_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='YES'  id='choice_68_139_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_139_0' id='label_68_139_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_139_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='NO'  id='choice_68_139_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_139_1' id='label_68_139_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_140\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.4 Of the nervous system, of the eyes or of the ears (e. g.: migraines, epilepsy, Parkinson&#039;s disease, paralysis, Alzheimer&#039;s disease, glaucoma, macular degeneration, vision loss, ADHD, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_140'>\n\t\t\t<div class='gchoice gchoice_68_140_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='YES'  id='choice_68_140_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_140_0' id='label_68_140_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_140_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='NO'  id='choice_68_140_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_140_1' id='label_68_140_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_141\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.5 Haematological or clotting (e. g.: thromboembolism, anaemia, haemophilia, leukaemia, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_141'>\n\t\t\t<div class='gchoice gchoice_68_141_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='YES'  id='choice_68_141_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_141_0' id='label_68_141_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_141_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='NO'  id='choice_68_141_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_141_1' id='label_68_141_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_142\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.6 Of the kidney, urological and genital tract, or gynaecological (e. g.: kidney failure, prostate problems, renal colic, sexually transmitted, gynaecological - breast, uterus, ovaries, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_142'>\n\t\t\t<div class='gchoice gchoice_68_142_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_142' type='radio' value='YES'  id='choice_68_142_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_142_0' id='label_68_142_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_142_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_142' type='radio' value='NO'  id='choice_68_142_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_142_1' id='label_68_142_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_143\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.7 Psychiatric (e. g.: anorexia, bulimia, depression, anxiety, psychosis, schizophrenia, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_143'>\n\t\t\t<div class='gchoice gchoice_68_143_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_143' type='radio' value='YES'  id='choice_68_143_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_143_0' id='label_68_143_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_143_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_143' type='radio' value='NO'  id='choice_68_143_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_143_1' id='label_68_143_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_144\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.8 Infectious diseases (e. g.: hepatitis, COVID-19, tuberculosis, parasitic infections, septicaemia, tropical diseases, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_144'>\n\t\t\t<div class='gchoice gchoice_68_144_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_144' type='radio' value='YES'  id='choice_68_144_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_144_0' id='label_68_144_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_144_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_144' type='radio' value='NO'  id='choice_68_144_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_144_1' id='label_68_144_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_145\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_145'>Please indicate which:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_145' id='input_68_145' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_68_146\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Other<\/h3><\/div><fieldset id=\"field_68_147\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Do you take any medication?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_147'>\n\t\t\t<div class='gchoice gchoice_68_147_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_147' type='radio' value='YES'  id='choice_68_147_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_147_0' id='label_68_147_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_147_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_147' type='radio' value='NO'  id='choice_68_147_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_147_1' id='label_68_147_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_148\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_148'>Indicate which, dose and frequency (regimen):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_148' id='input_68_148' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_149\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Do you consume alcohol or drugs or do you smoke?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_149'>\n\t\t\t<div class='gchoice gchoice_68_149_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='YES'  id='choice_68_149_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_149_0' id='label_68_149_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_149_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='NO'  id='choice_68_149_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_149_1' id='label_68_149_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_150\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_150'>Indicate the type, amount consumed and frequency:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_150' id='input_68_150' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_151\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >8. Do you have lesions or sequelae from a disease, congenital or hereditary disorder, malformations or an accident?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_151'>\n\t\t\t<div class='gchoice gchoice_68_151_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_151' type='radio' value='YES'  id='choice_68_151_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_151_0' id='label_68_151_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_151_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_151' type='radio' value='NO'  id='choice_68_151_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_151_1' id='label_68_151_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_152\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_152'>Please indicate which and provide a medical report:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_152' id='input_68_152' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_153\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >9. Do you have any recognised handicap or disability, or are you in the process of being assessed for any?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_153'>\n\t\t\t<div class='gchoice gchoice_68_153_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_153' type='radio' value='YES'  id='choice_68_153_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_153_0' id='label_68_153_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_153_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_153' type='radio' value='NO'  id='choice_68_153_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_153_1' id='label_68_153_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_154\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_154'>Please indicate which and provide a medical report:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_154' id='input_68_154' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_68_155' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_68_155' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_68_6' class='gform_page' data-js='page-field-id-155' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_68_6' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_68_267\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Individual 5<\/h3><\/div><fieldset id=\"field_68_156\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required 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' >Name<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_68_156'>\n                            \n                            <span id='input_68_156_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_68_156_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                    <input type='text' name='input_156.3' id='input_68_156_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_68_156_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_68_156_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                            <input type='text' name='input_156.6' id='input_68_156_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_68_157\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_157'>Date of birth<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_157' id='input_68_157' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_68_157_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_68_157_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_68_157' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_68_158\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_158'>NIF, NIE, or Passport<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_158' id='input_68_158' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_68_159\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_2col gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_159'>\n\t\t\t<div class='gchoice gchoice_68_159_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_159' type='radio' value='MALE'  id='choice_68_159_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_159_0' id='label_68_159_0' class='gform-field-label gform-field-label--type-inline'>MALE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_159_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_159' type='radio' value='FEMALE'  id='choice_68_159_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_159_1' id='label_68_159_1' class='gform-field-label gform-field-label--type-inline'>FEMALE<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_160\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_160'>Height in centimetres<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_160' id='input_68_160' type='number' step='any' min='50' max='240' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_68_160\" \/><div class='gfield_description instruction ' id='gfield_instruction_68_160'>Por favor, escribe un n\u00famero entre <strong>50<\/strong> y <strong>240<\/strong>.<\/div><\/div><\/div><div id=\"field_68_161\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_161'>Weight in kilograms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_161' id='input_68_161' type='number' step='any' min='2' max='250' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_68_161\" \/><div class='gfield_description instruction ' id='gfield_instruction_68_161'>Por favor, escribe un n\u00famero entre <strong>2<\/strong> y <strong>250<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_68_164\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1.Have you been admitted to a health centre in the last 10 years, or do you have any admissions scheduled?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_164'>\n\t\t\t<div class='gchoice gchoice_68_164_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_164' type='radio' value='YES'  id='choice_68_164_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_164_0' id='label_68_164_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_164_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_164' type='radio' value='NO'  id='choice_68_164_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_164_1' id='label_68_164_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_165\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_165'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_165' id='input_68_165' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_166\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2.Have you undergone any surgery, or are you scheduled to undergo any surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_166'>\n\t\t\t<div class='gchoice gchoice_68_166_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_166' type='radio' value='YES'  id='choice_68_166_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_166_0' id='label_68_166_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_166_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_166' type='radio' value='NO'  id='choice_68_166_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_166_1' id='label_68_166_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_167\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_167'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_167' id='input_68_167' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_168\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. Do you have or have you had any tumours or cancer?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_168'>\n\t\t\t<div class='gchoice gchoice_68_168_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='YES'  id='choice_68_168_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_168_0' id='label_68_168_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_168_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='NO'  id='choice_68_168_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_168_1' id='label_68_168_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_169\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_169'>Please specify which and the date(s) of diagnosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_169' id='input_68_169' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_170\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Have you or have you had any symptoms, pain or disorder persistently, regularly or recurringly, or are you under medical supervision or monitoring for any reason?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_170'>\n\t\t\t<div class='gchoice gchoice_68_170_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_170' type='radio' value='YES'  id='choice_68_170_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_170_0' id='label_68_170_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_170_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_170' type='radio' value='NO'  id='choice_68_170_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_170_1' id='label_68_170_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_171\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_171'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_171' id='input_68_171' class='textarea large'   maxlength='155'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_68_172\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Have you or have you had any of the following types of condition, injury or disorder?<\/h3><\/div><fieldset id=\"field_68_173\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.1 Cardiac, vascular, pulmonary or respiratory (e. g.: hypertension, arrhythmias, heart or circulatory failure, varices, asthma, emphysema, thrombosis, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_173'>\n\t\t\t<div class='gchoice gchoice_68_173_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_173' type='radio' value='YES'  id='choice_68_173_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_173_0' id='label_68_173_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_173_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_173' type='radio' value='NO'  id='choice_68_173_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_173_1' id='label_68_173_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_174\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.2 Metabolic (of the endocrine system) or of the digestive system (e. g.: of the liver or pancreas, gastric or duodenal ulcer, hernias, diabetes, thyroid disease, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_174'>\n\t\t\t<div class='gchoice gchoice_68_174_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_174' type='radio' value='YES'  id='choice_68_174_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_174_0' id='label_68_174_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_174_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_174' type='radio' value='NO'  id='choice_68_174_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_174_1' id='label_68_174_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_175\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.3 Rheumatic, bone or muscular (e. g.: arthritis, osteoarthritis, scoliosis, slipped disc, fibromyalgia, lupus, scleroderma, muscle disorder, trauma sequelae, psoriasis, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_175'>\n\t\t\t<div class='gchoice gchoice_68_175_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_175' type='radio' value='YES'  id='choice_68_175_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_175_0' id='label_68_175_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_175_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_175' type='radio' value='NO'  id='choice_68_175_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_175_1' id='label_68_175_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_176\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.4 Of the nervous system, of the eyes or of the ears (e. g.: migraines, epilepsy, Parkinson&#039;s disease, paralysis, Alzheimer&#039;s disease, glaucoma, macular degeneration, vision loss, ADHD, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_176'>\n\t\t\t<div class='gchoice gchoice_68_176_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_176' type='radio' value='YES'  id='choice_68_176_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_176_0' id='label_68_176_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_176_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_176' type='radio' value='NO'  id='choice_68_176_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_176_1' id='label_68_176_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_177\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.5 Haematological or clotting (e. g.: thromboembolism, anaemia, haemophilia, leukaemia, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_177'>\n\t\t\t<div class='gchoice gchoice_68_177_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='YES'  id='choice_68_177_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_177_0' id='label_68_177_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_177_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_177' type='radio' value='NO'  id='choice_68_177_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_177_1' id='label_68_177_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_178\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.6 Of the kidney, urological and genital tract, or gynaecological (e. g.: kidney failure, prostate problems, renal colic, sexually transmitted, gynaecological - breast, uterus, ovaries, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_178'>\n\t\t\t<div class='gchoice gchoice_68_178_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_178' type='radio' value='YES'  id='choice_68_178_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_178_0' id='label_68_178_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_178_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_178' type='radio' value='NO'  id='choice_68_178_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_178_1' id='label_68_178_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_179\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.7 Psychiatric (e. g.: anorexia, bulimia, depression, anxiety, psychosis, schizophrenia, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_179'>\n\t\t\t<div class='gchoice gchoice_68_179_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_179' type='radio' value='YES'  id='choice_68_179_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_179_0' id='label_68_179_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_179_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_179' type='radio' value='NO'  id='choice_68_179_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_179_1' id='label_68_179_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_180\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.8 Infectious diseases (e. g.: hepatitis, COVID-19, tuberculosis, parasitic infections, septicaemia, tropical diseases, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_180'>\n\t\t\t<div class='gchoice gchoice_68_180_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_180' type='radio' value='YES'  id='choice_68_180_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_180_0' id='label_68_180_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_180_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_180' type='radio' value='NO'  id='choice_68_180_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_180_1' id='label_68_180_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_181\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_181'>Please indicate which:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_181' id='input_68_181' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_68_182\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Other<\/h3><\/div><fieldset id=\"field_68_183\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Do you take any medication?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_183'>\n\t\t\t<div class='gchoice gchoice_68_183_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_183' type='radio' value='YES'  id='choice_68_183_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_183_0' id='label_68_183_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_183_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_183' type='radio' value='NO'  id='choice_68_183_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_183_1' id='label_68_183_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_184\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_184'>Indicate which, dose and frequency (regimen):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_184' id='input_68_184' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_185\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Do you consume alcohol or drugs or do you smoke?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_185'>\n\t\t\t<div class='gchoice gchoice_68_185_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_185' type='radio' value='YES'  id='choice_68_185_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_185_0' id='label_68_185_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_185_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_185' type='radio' value='NO'  id='choice_68_185_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_185_1' id='label_68_185_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_186\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_186'>Indicate the type, amount consumed and frequency:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_186' id='input_68_186' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_187\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >8. Do you have lesions or sequelae from a disease, congenital or hereditary disorder, malformations or an accident?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_187'>\n\t\t\t<div class='gchoice gchoice_68_187_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_187' type='radio' value='YES'  id='choice_68_187_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_187_0' id='label_68_187_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_187_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_187' type='radio' value='NO'  id='choice_68_187_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_187_1' id='label_68_187_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_188\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_188'>Please indicate which and provide a medical report:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_188' id='input_68_188' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_189\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >9. Do you have any recognised handicap or disability, or are you in the process of being assessed for any?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_189'>\n\t\t\t<div class='gchoice gchoice_68_189_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_189' type='radio' value='YES'  id='choice_68_189_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_189_0' id='label_68_189_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_189_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_189' type='radio' value='NO'  id='choice_68_189_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_189_1' id='label_68_189_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_190\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_190'>Please indicate which and provide a medical report:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_190' id='input_68_190' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_68_191' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_68_191' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_68_7' class='gform_page' data-js='page-field-id-191' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_68_7' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_68_268\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Individual 6<\/h3><\/div><fieldset id=\"field_68_192\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required 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' >Name<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_68_192'>\n                            \n                            <span id='input_68_192_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_68_192_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                    <input type='text' name='input_192.3' id='input_68_192_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_68_192_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_68_192_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                            <input type='text' name='input_192.6' id='input_68_192_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_68_193\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_193'>Date of birth<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_193' id='input_68_193' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_68_193_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_68_193_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_68_193' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_68_194\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_194'>NIF, NIE, or Passport<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_194' id='input_68_194' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_68_195\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_2col gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_195'>\n\t\t\t<div class='gchoice gchoice_68_195_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_195' type='radio' value='MALE'  id='choice_68_195_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_195_0' id='label_68_195_0' class='gform-field-label gform-field-label--type-inline'>MALE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_195_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_195' type='radio' value='FEMALE'  id='choice_68_195_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_195_1' id='label_68_195_1' class='gform-field-label gform-field-label--type-inline'>FEMALE<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_196\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_196'>Height in centimetres<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_196' id='input_68_196' type='number' step='any' min='50' max='240' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_68_196\" \/><div class='gfield_description instruction ' id='gfield_instruction_68_196'>Por favor, escribe un n\u00famero entre <strong>50<\/strong> y <strong>240<\/strong>.<\/div><\/div><\/div><div id=\"field_68_197\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_197'>Weight in kilograms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_197' id='input_68_197' type='number' step='any' min='2' max='250' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_68_197\" \/><div class='gfield_description instruction ' id='gfield_instruction_68_197'>Por favor, escribe un n\u00famero entre <strong>2<\/strong> y <strong>250<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_68_200\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1.Have you been admitted to a health centre in the last 10 years, or do you have any admissions scheduled?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_200'>\n\t\t\t<div class='gchoice gchoice_68_200_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_200' type='radio' value='YES'  id='choice_68_200_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_200_0' id='label_68_200_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_200_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_200' type='radio' value='NO'  id='choice_68_200_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_200_1' id='label_68_200_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_201\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_201'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_201' id='input_68_201' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_202\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2.Have you undergone any surgery, or are you scheduled to undergo any surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_202'>\n\t\t\t<div class='gchoice gchoice_68_202_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_202' type='radio' value='YES'  id='choice_68_202_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_202_0' id='label_68_202_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_202_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_202' type='radio' value='NO'  id='choice_68_202_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_202_1' id='label_68_202_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_203\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_203'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_203' id='input_68_203' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_204\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. Do you have or have you had any tumours or cancer?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_204'>\n\t\t\t<div class='gchoice gchoice_68_204_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_204' type='radio' value='YES'  id='choice_68_204_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_204_0' id='label_68_204_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_204_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_204' type='radio' value='NO'  id='choice_68_204_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_204_1' id='label_68_204_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_205\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_205'>Please specify which and the date(s) of diagnosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_205' id='input_68_205' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_206\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Have you or have you had any symptoms, pain or disorder persistently, regularly or recurringly, or are you under medical supervision or monitoring for any reason?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_206'>\n\t\t\t<div class='gchoice gchoice_68_206_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_206' type='radio' value='YES'  id='choice_68_206_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_206_0' id='label_68_206_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_206_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_206' type='radio' value='NO'  id='choice_68_206_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_206_1' id='label_68_206_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_207\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_207'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_207' id='input_68_207' class='textarea large'   maxlength='155'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_68_208\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Have you or have you had any of the following types of condition, injury or disorder?<\/h3><\/div><fieldset id=\"field_68_209\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.1 Cardiac, vascular, pulmonary or respiratory (e. g.: hypertension, arrhythmias, heart or circulatory failure, varices, asthma, emphysema, thrombosis, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_209'>\n\t\t\t<div class='gchoice gchoice_68_209_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_209' type='radio' value='YES'  id='choice_68_209_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_209_0' id='label_68_209_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_209_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_209' type='radio' value='NO'  id='choice_68_209_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_209_1' id='label_68_209_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_210\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.2 Metabolic (of the endocrine system) or of the digestive system (e. g.: of the liver or pancreas, gastric or duodenal ulcer, hernias, diabetes, thyroid disease, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_210'>\n\t\t\t<div class='gchoice gchoice_68_210_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_210' type='radio' value='YES'  id='choice_68_210_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_210_0' id='label_68_210_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_210_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_210' type='radio' value='NO'  id='choice_68_210_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_210_1' id='label_68_210_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_211\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.3 Rheumatic, bone or muscular (e. g.: arthritis, osteoarthritis, scoliosis, slipped disc, fibromyalgia, lupus, scleroderma, muscle disorder, trauma sequelae, psoriasis, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_211'>\n\t\t\t<div class='gchoice gchoice_68_211_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_211' type='radio' value='YES'  id='choice_68_211_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_211_0' id='label_68_211_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_211_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_211' type='radio' value='NO'  id='choice_68_211_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_211_1' id='label_68_211_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_212\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.4 Of the nervous system, of the eyes or of the ears (e. g.: migraines, epilepsy, Parkinson&#039;s disease, paralysis, Alzheimer&#039;s disease, glaucoma, macular degeneration, vision loss, ADHD, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_212'>\n\t\t\t<div class='gchoice gchoice_68_212_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='YES'  id='choice_68_212_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_212_0' id='label_68_212_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_212_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='NO'  id='choice_68_212_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_212_1' id='label_68_212_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_213\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.5 Haematological or clotting (e. g.: thromboembolism, anaemia, haemophilia, leukaemia, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_213'>\n\t\t\t<div class='gchoice gchoice_68_213_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_213' type='radio' value='YES'  id='choice_68_213_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_213_0' id='label_68_213_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_213_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_213' type='radio' value='NO'  id='choice_68_213_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_213_1' id='label_68_213_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_214\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.6 Of the kidney, urological and genital tract, or gynaecological (e. g.: kidney failure, prostate problems, renal colic, sexually transmitted, gynaecological - breast, uterus, ovaries, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_214'>\n\t\t\t<div class='gchoice gchoice_68_214_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_214' type='radio' value='YES'  id='choice_68_214_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_214_0' id='label_68_214_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_214_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_214' type='radio' value='NO'  id='choice_68_214_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_214_1' id='label_68_214_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_215\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.7 Psychiatric (e. g.: anorexia, bulimia, depression, anxiety, psychosis, schizophrenia, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_215'>\n\t\t\t<div class='gchoice gchoice_68_215_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_215' type='radio' value='YES'  id='choice_68_215_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_215_0' id='label_68_215_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_215_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_215' type='radio' value='NO'  id='choice_68_215_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_215_1' id='label_68_215_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_216\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.8 Infectious diseases (e. g.: hepatitis, COVID-19, tuberculosis, parasitic infections, septicaemia, tropical diseases, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_216'>\n\t\t\t<div class='gchoice gchoice_68_216_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_216' type='radio' value='YES'  id='choice_68_216_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_216_0' id='label_68_216_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_216_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_216' type='radio' value='NO'  id='choice_68_216_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_216_1' id='label_68_216_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_217\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_217'>Please indicate which:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_217' id='input_68_217' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_68_218\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Other<\/h3><\/div><fieldset id=\"field_68_219\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Do you take any medication?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_219'>\n\t\t\t<div class='gchoice gchoice_68_219_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_219' type='radio' value='YES'  id='choice_68_219_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_219_0' id='label_68_219_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_219_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_219' type='radio' value='NO'  id='choice_68_219_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_219_1' id='label_68_219_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_220\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_220'>Indicate which, dose and frequency (regimen):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_220' id='input_68_220' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_221\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Do you consume alcohol or drugs or do you smoke?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_221'>\n\t\t\t<div class='gchoice gchoice_68_221_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_221' type='radio' value='YES'  id='choice_68_221_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_221_0' id='label_68_221_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_221_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_221' type='radio' value='NO'  id='choice_68_221_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_221_1' id='label_68_221_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_222\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_222'>Indicate the type, amount consumed and frequency:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_222' id='input_68_222' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_223\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >8. Do you have lesions or sequelae from a disease, congenital or hereditary disorder, malformations or an accident?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_223'>\n\t\t\t<div class='gchoice gchoice_68_223_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_223' type='radio' value='YES'  id='choice_68_223_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_223_0' id='label_68_223_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_223_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_223' type='radio' value='NO'  id='choice_68_223_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_223_1' id='label_68_223_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_224\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_224'>Please indicate which and provide a medical report:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_224' id='input_68_224' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_225\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >9. Do you have any recognised handicap or disability, or are you in the process of being assessed for any?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_225'>\n\t\t\t<div class='gchoice gchoice_68_225_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_225' type='radio' value='YES'  id='choice_68_225_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_225_0' id='label_68_225_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_225_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_225' type='radio' value='NO'  id='choice_68_225_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_225_1' id='label_68_225_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_226\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_226'>Please indicate which and provide a medical report:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_226' id='input_68_226' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_68_227' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_68_227' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_68_8' class='gform_page' data-js='page-field-id-227' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_68_8' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_68_269\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Individual 7<\/h3><\/div><fieldset id=\"field_68_228\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required 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' >Name<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_68_228'>\n                            \n                            <span id='input_68_228_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_68_228_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                    <input type='text' name='input_228.3' id='input_68_228_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_68_228_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_68_228_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                            <input type='text' name='input_228.6' id='input_68_228_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_68_229\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_229'>Date of birth<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_229' id='input_68_229' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_68_229_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_68_229_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_68_229' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_68_230\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_230'>NIF, NIE, or Passport<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_230' id='input_68_230' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_68_231\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_2col gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_231'>\n\t\t\t<div class='gchoice gchoice_68_231_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_231' type='radio' value='MALE'  id='choice_68_231_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_231_0' id='label_68_231_0' class='gform-field-label gform-field-label--type-inline'>MALE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_231_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_231' type='radio' value='FEMALE'  id='choice_68_231_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_231_1' id='label_68_231_1' class='gform-field-label gform-field-label--type-inline'>FEMALE<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_232\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_232'>Height in centimetres<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_232' id='input_68_232' type='number' step='any' min='50' max='240' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_68_232\" \/><div class='gfield_description instruction ' id='gfield_instruction_68_232'>Por favor, escribe un n\u00famero entre <strong>50<\/strong> y <strong>240<\/strong>.<\/div><\/div><\/div><div id=\"field_68_233\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_233'>Weight in kilograms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_233' id='input_68_233' type='number' step='any' min='2' max='250' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_68_233\" \/><div class='gfield_description instruction ' id='gfield_instruction_68_233'>Por favor, escribe un n\u00famero entre <strong>2<\/strong> y <strong>250<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_68_236\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1.Have you been admitted to a health centre in the last 10 years, or do you have any admissions scheduled?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_236'>\n\t\t\t<div class='gchoice gchoice_68_236_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_236' type='radio' value='YES'  id='choice_68_236_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_236_0' id='label_68_236_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_236_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_236' type='radio' value='NO'  id='choice_68_236_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_236_1' id='label_68_236_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_237\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_237'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_237' id='input_68_237' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_238\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2.Have you undergone any surgery, or are you scheduled to undergo any surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_238'>\n\t\t\t<div class='gchoice gchoice_68_238_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_238' type='radio' value='YES'  id='choice_68_238_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_238_0' id='label_68_238_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_238_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_238' type='radio' value='NO'  id='choice_68_238_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_238_1' id='label_68_238_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_239\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_239'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_239' id='input_68_239' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_240\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. Do you have or have you had any tumours or cancer?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_240'>\n\t\t\t<div class='gchoice gchoice_68_240_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_240' type='radio' value='YES'  id='choice_68_240_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_240_0' id='label_68_240_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_240_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_240' type='radio' value='NO'  id='choice_68_240_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_240_1' id='label_68_240_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_241\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_241'>Please specify which and the date(s) of diagnosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_241' id='input_68_241' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_242\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Have you or have you had any symptoms, pain or disorder persistently, regularly or recurringly, or are you under medical supervision or monitoring for any reason?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_242'>\n\t\t\t<div class='gchoice gchoice_68_242_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_242' type='radio' value='YES'  id='choice_68_242_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_242_0' id='label_68_242_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_242_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_242' type='radio' value='NO'  id='choice_68_242_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_242_1' id='label_68_242_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_243\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_243'>Please indicate the reason and the date(s):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_243' id='input_68_243' class='textarea large'   maxlength='155'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_68_244\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Have you or have you had any of the following types of condition, injury or disorder?<\/h3><\/div><fieldset id=\"field_68_245\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.1 Cardiac, vascular, pulmonary or respiratory (e. g.: hypertension, arrhythmias, heart or circulatory failure, varices, asthma, emphysema, thrombosis, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_245'>\n\t\t\t<div class='gchoice gchoice_68_245_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_245' type='radio' value='YES'  id='choice_68_245_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_245_0' id='label_68_245_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_245_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_245' type='radio' value='NO'  id='choice_68_245_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_245_1' id='label_68_245_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_246\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.2 Metabolic (of the endocrine system) or of the digestive system (e. g.: of the liver or pancreas, gastric or duodenal ulcer, hernias, diabetes, thyroid disease, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_246'>\n\t\t\t<div class='gchoice gchoice_68_246_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_246' type='radio' value='YES'  id='choice_68_246_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_246_0' id='label_68_246_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_246_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_246' type='radio' value='NO'  id='choice_68_246_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_246_1' id='label_68_246_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_247\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.3 Rheumatic, bone or muscular (e. g.: arthritis, osteoarthritis, scoliosis, slipped disc, fibromyalgia, lupus, scleroderma, muscle disorder, trauma sequelae, psoriasis, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_247'>\n\t\t\t<div class='gchoice gchoice_68_247_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_247' type='radio' value='YES'  id='choice_68_247_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_247_0' id='label_68_247_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_247_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_247' type='radio' value='NO'  id='choice_68_247_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_247_1' id='label_68_247_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_248\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.4 Of the nervous system, of the eyes or of the ears (e. g.: migraines, epilepsy, Parkinson&#039;s disease, paralysis, Alzheimer&#039;s disease, glaucoma, macular degeneration, vision loss, ADHD, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_248'>\n\t\t\t<div class='gchoice gchoice_68_248_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_248' type='radio' value='YES'  id='choice_68_248_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_248_0' id='label_68_248_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_248_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_248' type='radio' value='NO'  id='choice_68_248_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_248_1' id='label_68_248_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_249\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.5 Haematological or clotting (e. g.: thromboembolism, anaemia, haemophilia, leukaemia, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_249'>\n\t\t\t<div class='gchoice gchoice_68_249_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_249' type='radio' value='YES'  id='choice_68_249_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_249_0' id='label_68_249_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_249_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_249' type='radio' value='NO'  id='choice_68_249_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_249_1' id='label_68_249_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_250\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.6 Of the kidney, urological and genital tract, or gynaecological (e. g.: kidney failure, prostate problems, renal colic, sexually transmitted, gynaecological - breast, uterus, ovaries, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_250'>\n\t\t\t<div class='gchoice gchoice_68_250_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_250' type='radio' value='YES'  id='choice_68_250_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_250_0' id='label_68_250_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_250_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_250' type='radio' value='NO'  id='choice_68_250_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_250_1' id='label_68_250_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_251\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.7 Psychiatric (e. g.: anorexia, bulimia, depression, anxiety, psychosis, schizophrenia, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_251'>\n\t\t\t<div class='gchoice gchoice_68_251_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_251' type='radio' value='YES'  id='choice_68_251_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_251_0' id='label_68_251_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_251_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_251' type='radio' value='NO'  id='choice_68_251_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_251_1' id='label_68_251_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_252\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5.8 Infectious diseases (e. g.: hepatitis, COVID-19, tuberculosis, parasitic infections, septicaemia, tropical diseases, etc.).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_252'>\n\t\t\t<div class='gchoice gchoice_68_252_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_252' type='radio' value='YES'  id='choice_68_252_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_252_0' id='label_68_252_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_252_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_252' type='radio' value='NO'  id='choice_68_252_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_252_1' id='label_68_252_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_253\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_253'>Please indicate which:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_253' id='input_68_253' class='textarea large'   maxlength='460'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_68_254\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Other<\/h3><\/div><fieldset id=\"field_68_255\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Do you take any medication?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_255'>\n\t\t\t<div class='gchoice gchoice_68_255_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_255' type='radio' value='YES'  id='choice_68_255_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_255_0' id='label_68_255_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_255_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_255' type='radio' value='NO'  id='choice_68_255_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_255_1' id='label_68_255_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_256\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_256'>Indicate which, dose and frequency (regimen):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_256' id='input_68_256' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_257\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Do you consume alcohol or drugs or do you smoke?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_257'>\n\t\t\t<div class='gchoice gchoice_68_257_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_257' type='radio' value='YES'  id='choice_68_257_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_257_0' id='label_68_257_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_257_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_257' type='radio' value='NO'  id='choice_68_257_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_257_1' id='label_68_257_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_258\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_258'>Indicate the type, amount consumed and frequency:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_258' id='input_68_258' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_259\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >8. Do you have lesions or sequelae from a disease, congenital or hereditary disorder, malformations or an accident?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_259'>\n\t\t\t<div class='gchoice gchoice_68_259_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_259' type='radio' value='YES'  id='choice_68_259_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_259_0' id='label_68_259_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_259_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_259' type='radio' value='NO'  id='choice_68_259_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_259_1' id='label_68_259_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_260\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_260'>Please indicate which and provide a medical report:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_260' id='input_68_260' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_68_261\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >9. Do you have any recognised handicap or disability, or are you in the process of being assessed for any?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_261'>\n\t\t\t<div class='gchoice gchoice_68_261_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_261' type='radio' value='YES'  id='choice_68_261_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_261_0' id='label_68_261_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_261_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_261' type='radio' value='NO'  id='choice_68_261_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_261_1' id='label_68_261_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_68_262\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_262'>Please indicate which and provide a medical report:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_262' id='input_68_262' class='textarea large'   maxlength='150'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_68_37' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_68_37' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_68_9' class='gform_page' data-js='page-field-id-37' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_68_9' class='gform_fields top_label form_sublabel_above description_below validation_below'><fieldset id=\"field_68_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Firma<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_68_36'>\n\t\t\t<div class='gchoice gchoice_68_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='In your own name'  id='choice_68_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_36_0' id='label_68_36_0' class='gform-field-label gform-field-label--type-inline'>En su propio nombre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_68_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='As a policy contracting party or family member of legal age'  id='choice_68_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_68_36_1' id='label_68_36_1' class='gform-field-label gform-field-label--type-inline'>Como titular de la p\u00f3liza o familiar con mayor\u00eda de edad<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_68_40\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required 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' >Nombre<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_68_40'>\n                            \n                            <span id='input_68_40_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_68_40_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                    <input type='text' name='input_40.3' id='input_68_40_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_68_40_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_68_40_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                            <input type='text' name='input_40.6' id='input_68_40_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_68_39\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_68_39'>Su NIF, NIE, or pasaporte<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_68_39' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_68_38\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Firma<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_signature\"><input type='hidden' value='' name='input_38' id='input_68_38_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_68_38_Container' class='gfield_signature_container' style='height:180px; width:300px; ' ><canvas id=\"input_68_38\" 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_68_38_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id='input_68_38_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_68_38_data' name='input_68_38_data' value=''><\/div><\/div><\/fieldset><div id=\"field_68_43\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_above 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=\"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_68_43'>QR Entry<\/label><div class='ginput_container ginput_container_number'><input name='input_43' id='input_68_43' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_68_272\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_above 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=\"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_68_272'>Contract Entry (Asisa)<\/label><div class='ginput_container ginput_container_number'><input name='input_272' id='input_68_272' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_68_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_below 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