{"id":2327,"date":"2015-11-10T13:34:35","date_gmt":"2015-11-10T19:34:35","guid":{"rendered":"https:\/\/ideas26.com\/mt\/?page_id=2327"},"modified":"2026-04-04T16:39:50","modified_gmt":"2026-04-04T22:39:50","slug":"cuestionario-de-evaluacion-medica","status":"publish","type":"page","link":"https:\/\/ideas26.com\/mt\/formatos-y-descargables\/cuestionario-de-evaluacion-medica\/","title":{"rendered":"Cuestionario de Evaluaci\u00f3n M\u00e9dica"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f4465-o1\" lang=\"es-ES\" dir=\"ltr\" data-wpcf7-id=\"4465\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/mt\/wp-json\/wp\/v2\/pages\/2327#wpcf7-f4465-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"4465\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.7\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"es_ES\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f4465-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<div class=\"row\">\n\t<h3>Bienvenido, te presentamos nuestro cuestionario de evaluaci\u00f3n m\u00e9dica, te pedimos contestar cada una de las preguntas de forma clara y honesta, recuerda que estamos evaluando lo m\u00e1s importante: TU SALUD.\n\t<\/h3>\n\t<h4>Gracias por tu tiempo, para nosotros eres importante.\n\t<\/h4>\n\t<h6>Toda la informaci\u00f3n proporcionada ser\u00e1 utilizada de manera interna y como parte de su expediente. Si desea conocer nuestro aviso de privacidad de click <a href=\"https:\/\/ideas26.com\/mt\/aviso-de-privacidad\/\" target=\"_blank\" style=\"font-weight:bold\">aqu\u00ed<\/a>\n\t<\/h6>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-3\" style=\"float:right\">\n\t\t<p>Fecha: <span class=\"wpcf7-form-control-wrap\" data-name=\"fecha\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" id=\"fechaDeRegistro\" aria-invalid=\"false\" placeholder=\"Seleccione la fecha de hoy\" value=\"\" type=\"date\" name=\"fecha\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<h3>I. Informaci\u00f3n General\n\t<\/h3>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-5\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"firstname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre (s)\" value=\"\" type=\"text\" name=\"firstname\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-5\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"lastname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Apellidos\" value=\"\" type=\"text\" name=\"lastname\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-2\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"edad\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"edad\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Edad\" value=\"\" type=\"text\" name=\"edad\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-4\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"emailaddress\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"E-mail\" value=\"\" type=\"email\" name=\"emailaddress\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-4\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono\" value=\"\" type=\"text\" name=\"phone\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-4\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"telefonoCel\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Celular\" value=\"\" type=\"text\" name=\"telefonoCel\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-6\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Ocupacion\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Ocupaci\u00f3n\" value=\"\" type=\"text\" name=\"Ocupacion\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-6\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Ciudad\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Ciudad donde radica\" value=\"\" type=\"text\" name=\"Ciudad\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-2\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"peso\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Peso\" value=\"\" type=\"text\" name=\"peso\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-2\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"estatura\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Estatura\" value=\"\" type=\"text\" name=\"estatura\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-4\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"imc\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"IMC (Indice de masa corporal)*\" value=\"\" type=\"text\" name=\"imc\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-6\" style=\"margin-top:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"procedimientoInteresado\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Procedimiento en el que estamos interesados\" value=\"\" type=\"text\" name=\"procedimientoInteresado\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-6\">\n\t\t<p>\u00bfC\u00f3mo supo de nosotros? <span class=\"wpcf7-form-control-wrap\" data-name=\"comoSeEntero\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"comoSeEntero\"><option value=\"Internet\">Internet<\/option><option value=\"Facebook\">Facebook<\/option><option value=\"Recomendaci\u00f3n\">Recomendaci\u00f3n<\/option><option value=\"Otro\">Otro<\/option><\/select><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<hr style=\"margin-top:10px\" \/>\n<div class=\"row\">\n\t<h3>Antecedentes Heredo-familiares\n\t<\/h3>\n\t<h5>Seleccione todas las enfermedades que existan en su familia (Pap\u00e1, mam\u00e1, hermanos, abuelos, t\u00edos y primos de primer grado)\n\t<\/h5>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-6\" style=\"margin-bottom:10px\">\n\t\t<p>Diabetes: <span class=\"wpcf7-form-control-wrap\" data-name=\"diabetesOpcion\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><input type=\"radio\" name=\"diabetesOpcion\" value=\"S\u00ed\" checked=\"checked\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"diabetesOpcion\" value=\"No\" \/><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-6\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"diabetesQuien\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"\u00bfQuien?\" value=\"\" type=\"text\" name=\"diabetesQuien\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-6\" style=\"margin-bottom:10px\">\n\t\t<p>Hipertension: <span class=\"wpcf7-form-control-wrap\" data-name=\"hipertensionOpcion\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><input type=\"radio\" name=\"hipertensionOpcion\" value=\"S\u00ed\" checked=\"checked\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"hipertensionOpcion\" value=\"No\" \/><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-6\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"hipertensionQuien\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"\u00bfQuien?\" value=\"\" type=\"text\" name=\"hipertensionQuien\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-6\" style=\"margin-bottom:10px\">\n\t\t<p>Cancer: <span class=\"wpcf7-form-control-wrap\" data-name=\"cancerOpcion\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><input type=\"radio\" name=\"cancerOpcion\" value=\"S\u00ed\" checked=\"checked\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"cancerOpcion\" value=\"No\" \/><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-3\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"cancerQuien\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"\u00bfQuien?\" value=\"\" type=\"text\" name=\"cancerQuien\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-3\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"cancerOrgano\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"\u00bfEn qu\u00e9 organo?\" value=\"\" type=\"text\" name=\"cancerOrgano\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-12\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"OtraEnfermedad\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Otra enfermedad\" value=\"\" type=\"text\" name=\"OtraEnfermedad\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<hr style=\"margin-top:10px\" \/>\n<div class=\"row\">\n\t<h3>Antecedentes personales\n\t<\/h3>\n\t<h5>Enfermedades\n\t<\/h5>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-4\" style=\"margin-bottom:10px\">\n\t\t<p>Resistencia a la insulina: <span class=\"wpcf7-form-control-wrap\" data-name=\"resistenciaInsulinaOpcion\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><input type=\"radio\" name=\"resistenciaInsulinaOpcion\" value=\"S\u00ed\" checked=\"checked\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"resistenciaInsulinaOpcion\" value=\"No\" \/><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-8\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"InsuliinaMedicamentos\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Medicamentos actuales\" value=\"\" type=\"text\" name=\"InsuliinaMedicamentos\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-4\" style=\"margin-bottom:10px\">\n\t\t<p>Diabetes: <span class=\"wpcf7-form-control-wrap\" data-name=\"diabetesPersonalOpcion\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><input type=\"radio\" name=\"diabetesPersonalOpcion\" value=\"S\u00ed\" checked=\"checked\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"diabetesPersonalOpcion\" value=\"No\" \/><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-4\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"diabetesFecha\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Fecha de diagn\u00f3stico\" value=\"\" type=\"text\" name=\"diabetesFecha\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-4\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"diabetesMedicamentos\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Medicamentos actuales\" value=\"\" type=\"text\" name=\"diabetesMedicamentos\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-4\" style=\"margin-bottom:10px\">\n\t\t<p>Hipertension: <span class=\"wpcf7-form-control-wrap\" data-name=\"HipertensionPersonalOpcion\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><input type=\"radio\" name=\"HipertensionPersonalOpcion\" value=\"S\u00ed\" checked=\"checked\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"HipertensionPersonalOpcion\" value=\"No\" \/><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-4\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"HipertensionFecha\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Fecha de diagn\u00f3stico\" value=\"\" type=\"text\" name=\"HipertensionFecha\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-4\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"HipertensionMedicamentos\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Medicamentos actuales\" value=\"\" type=\"text\" name=\"HipertensionMedicamentos\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-4\" style=\"margin-bottom:10px\">\n\t\t<p>Problemas Tiroides: <span class=\"wpcf7-form-control-wrap\" data-name=\"TiroidesPersonalOpcion\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><input type=\"radio\" name=\"TiroidesPersonalOpcion\" value=\"S\u00ed\" checked=\"checked\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"TiroidesPersonalOpcion\" value=\"No\" \/><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-4\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"TiroidesFecha\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Fecha de diagn\u00f3stico\" value=\"\" type=\"text\" name=\"TiroidesFecha\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-4\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"TiroidesMedicamentos\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Medicamentos actuales\" value=\"\" type=\"text\" name=\"TiroidesMedicamentos\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-12\" style=\"margin-bottom:10px\">\n\t\t<p>Dolores articulares: <span class=\"wpcf7-form-control-wrap\" data-name=\"doloresArticulares\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><input type=\"radio\" name=\"doloresArticulares\" value=\"S\u00ed\" checked=\"checked\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"doloresArticulares\" value=\"No\" \/><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-12\" style=\"margin-bottom:10px\">\n\t\t<p>Compromiso emocional por no alcanzar el control de peso (des\u00e1nimo, tristeza, enojo): <span class=\"wpcf7-form-control-wrap\" data-name=\"compromisoEmocional\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><input type=\"radio\" name=\"compromisoEmocional\" value=\"S\u00ed\" checked=\"checked\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"compromisoEmocional\" value=\"No\" \/><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-3\" style=\"margin-bottom:10px\">\n\t\t<p>Apnea del sue\u00f1o: <span class=\"wpcf7-form-control-wrap\" data-name=\"apneaPersonalOpcion\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><input type=\"radio\" name=\"apneaPersonalOpcion\" value=\"S\u00ed\" checked=\"checked\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"apneaPersonalOpcion\" value=\"No\" \/><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-3\" style=\"margin-bottom:10px\">\n\t\t<p>Usa CPAP: <span class=\"wpcf7-form-control-wrap\" data-name=\"CPAPPersonalOpcion\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><input type=\"radio\" name=\"CPAPPersonalOpcion\" value=\"S\u00ed\" checked=\"checked\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"CPAPPersonalOpcion\" value=\"No\" \/><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-12\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"otrasEnfermedades\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Otras enfermedades\" name=\"otrasEnfermedades\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-12\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"medicamentosUsados\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Medicamentos\/suplementos que est\u00e9 utilizando\" name=\"medicamentosUsados\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-12\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"cirugias\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Cirug\u00edas que te hayas realizado, con fecha\" name=\"cirugias\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-12\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"complicacionesCirugia\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Describa si existi\u00f3 alguna complicaci\u00f3n en la cirug\u00eda.\" name=\"complicacionesCirugia\"><\/textarea><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<hr style=\"margin-top:10px\" \/>\n<div class=\"row\">\n\t<h5>AGO\n\t<\/h5>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-3\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"embarazos\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"N\u00famero de embarazos\" value=\"\" type=\"text\" name=\"embarazos\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-3\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"partos\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"partos\" value=\"\" type=\"text\" name=\"partos\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-3\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"cesareas\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"cesareas\" value=\"\" type=\"text\" name=\"cesareas\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-3\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"abortos\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"abortos\" value=\"\" type=\"text\" name=\"abortos\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-6\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"complicacionesEmbarazos\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Complicaciones en sus embarazos\" value=\"\" type=\"text\" name=\"complicacionesEmbarazos\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-6\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"metodoPlanificacion\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"M\u00e9todo de planificaci\u00f3n familiar\" value=\"\" type=\"text\" name=\"metodoPlanificacion\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-4\" style=\"margin-bottom:10px\">\n\t\t<p>Consumo de tabaco: <span class=\"wpcf7-form-control-wrap\" data-name=\"tabaco\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><input type=\"radio\" name=\"tabaco\" value=\"S\u00ed\" checked=\"checked\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"tabaco\" value=\"No\" \/><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-8\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"cantidadCigarros\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"N\u00famero de cigarrillos al d\u00eda o semana\" value=\"\" type=\"text\" name=\"cantidadCigarros\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-4\" style=\"margin-bottom:10px\">\n\t\t<p>Reflujo: <span class=\"wpcf7-form-control-wrap\" data-name=\"reflujo\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><input type=\"radio\" name=\"reflujo\" value=\"S\u00ed\" checked=\"checked\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"reflujo\" value=\"No\" \/><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-8\" style=\"margin-bottom:10px\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ReflujoMedicamentos\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Medicamentos utilizados\" value=\"\" type=\"text\" name=\"ReflujoMedicamentos\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<hr style=\"margin-top:10px\" \/>\n<div class=\"row\">\n\t<div class=\"col-md-12\" style=\"margin-bottom:10px\">\n\t\t<p>Agradecemos tu valioso tiempo al contestar este cuestionario el cual nos ser\u00e1 de mucha utilidad para tener un mejor diagn\u00f3stico y poder cuidar tu salud de la mejor manera.\n\t\t<\/p>\n\t\t<p>Si tienes cualquier duda al respecto en el llenado del mismo, no dudes en comunicarte con nosotros para apoyarte\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\" style=\"margin:30px 0;float:right\">\n\t<div class=\"col-md-12\">\n\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner appointment-submit\" type=\"submit\" value=\"Enviar\" \/>\n\t\t<\/p>\n\t<\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/vc_column][\/vc_row]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row][vc_column][\/vc_column][\/vc_row]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":2316,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2327","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/ideas26.com\/mt\/wp-json\/wp\/v2\/pages\/2327","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/ideas26.com\/mt\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/ideas26.com\/mt\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/ideas26.com\/mt\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/ideas26.com\/mt\/wp-json\/wp\/v2\/comments?post=2327"}],"version-history":[{"count":0,"href":"https:\/\/ideas26.com\/mt\/wp-json\/wp\/v2\/pages\/2327\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/ideas26.com\/mt\/wp-json\/wp\/v2\/pages\/2316"}],"wp:attachment":[{"href":"https:\/\/ideas26.com\/mt\/wp-json\/wp\/v2\/media?parent=2327"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}