{"id":556,"date":"2023-12-05T09:37:52","date_gmt":"2023-12-05T14:37:52","guid":{"rendered":"https:\/\/orobeautyspa.com\/?page_id=556"},"modified":"2023-12-05T09:37:52","modified_gmt":"2023-12-05T14:37:52","slug":"historia-medica-confidencial-de-nutricion","status":"publish","type":"page","link":"https:\/\/orobeautyspa.com\/en\/historia-medica-confidencial-de-nutricion\/","title":{"rendered":"Historia M\u00e9dica confidencial de nutrici\u00f3n"},"content":{"rendered":"<script type=\"text\/javascript\">var 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gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_1\"><label class='gfield_label gform-field-label' for='input_5_1' >Fecha de hoy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_1' id='input_5_1' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_1_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_1_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_1' class='gform_hidden' value='https:\/\/orobeautyspa.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_3\"  class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_3\"><label class='gfield_label gform-field-label' for='input_5_3' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_5_3' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_4\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_4\"><h3 class=\"gsection_title\">Informaci\u00f3n personal<\/h3><\/div><fieldset id=\"field_5_5\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_5\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/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_5_5'>\n                            \n                            <span id='input_5_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_5_5_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_5_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_5_5_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_5_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_6\"  class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_6\"><label class='gfield_label gform-field-label' for='input_5_6' >Tel\u00e9fono<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_5_6' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_7\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_7\"><label class='gfield_label gform-field-label' for='input_5_7' >Fecha de nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_7' id='input_5_7' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_7_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_7_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_7' class='gform_hidden' value='https:\/\/orobeautyspa.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_8\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_8\"><label class='gfield_label gform-field-label' for='input_5_8' >Pa\u00eds y ciudad donde vive<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_5_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_5_9\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_9\"><legend class='gfield_label gform-field-label'  >Estado Civ\u00edl<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_9'>\n\t\t\t<div class='gchoice gchoice_5_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Soltero'  id='choice_5_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_9_0' id='label_5_9_0' class='gform-field-label gform-field-label--type-inline'>Soltero<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Comprometido'  id='choice_5_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_9_1' id='label_5_9_1' class='gform-field-label gform-field-label--type-inline'>Comprometido<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_9_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Casado'  id='choice_5_9_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_9_2' id='label_5_9_2' class='gform-field-label gform-field-label--type-inline'>Casado<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_9_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Divorciado'  id='choice_5_9_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_9_3' id='label_5_9_3' class='gform-field-label gform-field-label--type-inline'>Divorciado<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_10\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_10\"><legend class='gfield_label gform-field-label'  >Hijos?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_10'>\n\t\t\t<div class='gchoice gchoice_5_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Si'  id='choice_5_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_10_0' id='label_5_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_5_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='No'  id='choice_5_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_10_1' id='label_5_10_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_11\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_11\"><label class='gfield_label gform-field-label' for='input_5_11' >Profesi\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_5_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_5_12\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_12\"><legend class='gfield_label gform-field-label'  >Horas laborales por semana<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_12'>\n\t\t\t<div class='gchoice gchoice_5_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='1-10 horas'  id='choice_5_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_12_0' id='label_5_12_0' class='gform-field-label gform-field-label--type-inline'>1-10 horas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='10-20 horas'  id='choice_5_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_12_1' id='label_5_12_1' class='gform-field-label gform-field-label--type-inline'>10-20 horas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='20-30 horas'  id='choice_5_12_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_12_2' id='label_5_12_2' class='gform-field-label gform-field-label--type-inline'>20-30 horas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='30-40 horas'  id='choice_5_12_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_12_3' id='label_5_12_3' class='gform-field-label gform-field-label--type-inline'>30-40 horas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_12_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='+40 horas'  id='choice_5_12_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_12_4' id='label_5_12_4' class='gform-field-label gform-field-label--type-inline'>+40 horas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_13\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_13\"><label class='gfield_label gform-field-label' for='input_5_13' >Peso actual en libras<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_5_13' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_14\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_14\"><h3 class=\"gsection_title\">Informaci\u00f3n de salud<\/h3><\/div><fieldset id=\"field_5_15\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_15\"><legend class='gfield_label gform-field-label'  >\u00bfLe gustar\u00eda mejorar su peso?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_15'>\n\t\t\t<div class='gchoice gchoice_5_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Subir de peso'  id='choice_5_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_15_0' id='label_5_15_0' class='gform-field-label gform-field-label--type-inline'>Subir de peso<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Bajar de peso'  id='choice_5_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_15_1' id='label_5_15_1' class='gform-field-label gform-field-label--type-inline'>Bajar de peso<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_15_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Mantener mi peso'  id='choice_5_15_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_15_2' id='label_5_15_2' class='gform-field-label gform-field-label--type-inline'>Mantener mi peso<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_17\"  class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_17\"><label class='gfield_label gform-field-label' for='input_5_17' >Haga una lista de 5 principales preocupaciones de su salud<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_5_17' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_18\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_18\"><legend class='gfield_label gform-field-label'  >\u00bfCu\u00e1l es su grupo sangu\u00edneo?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_18'>\n\t\t\t<div class='gchoice gchoice_5_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='a'  id='choice_5_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_18_0' id='label_5_18_0' class='gform-field-label gform-field-label--type-inline'>a<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='b'  id='choice_5_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_18_1' id='label_5_18_1' class='gform-field-label gform-field-label--type-inline'>b<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_18_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Ab'  id='choice_5_18_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_18_2' id='label_5_18_2' class='gform-field-label gform-field-label--type-inline'>Ab<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_18_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='o'  id='choice_5_18_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_18_3' id='label_5_18_3' class='gform-field-label gform-field-label--type-inline'>o<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_19\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_19\"><legend class='gfield_label gform-field-label'  >\u00bfHa tenido alguna enfermedad grave, operaci\u00f3n o lesi\u00f3n?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_19'>\n\t\t\t<div class='gchoice gchoice_5_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Si'  id='choice_5_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_19_0' id='label_5_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_5_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_5_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_19_1' id='label_5_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_20\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_20\"><label class='gfield_label gform-field-label' for='input_5_20' >En caso de un Si, Especifique<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_5_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_5_21\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_21\"><legend class='gfield_label gform-field-label'  >\u00bfC\u00f3mo es su sue\u00f1o (descanso)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_21'>\n\t\t\t<div class='gchoice gchoice_5_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Excelente'  id='choice_5_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_21_0' id='label_5_21_0' class='gform-field-label gform-field-label--type-inline'>Excelente<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Bueno'  id='choice_5_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_21_1' id='label_5_21_1' class='gform-field-label gform-field-label--type-inline'>Bueno<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_21_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Regular'  id='choice_5_21_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_21_2' id='label_5_21_2' class='gform-field-label gform-field-label--type-inline'>Regular<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_21_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Malo'  id='choice_5_21_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_21_3' id='label_5_21_3' class='gform-field-label gform-field-label--type-inline'>Malo<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_22\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_22\"><legend class='gfield_label gform-field-label'  >Estre\u00f1imiento, diarrea, gases<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_22'>\n\t\t\t<div class='gchoice gchoice_5_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Siempre'  id='choice_5_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_22_0' id='label_5_22_0' class='gform-field-label gform-field-label--type-inline'>Siempre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Con frecuencia'  id='choice_5_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_22_1' id='label_5_22_1' class='gform-field-label gform-field-label--type-inline'>Con frecuencia<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_22_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='A veces'  id='choice_5_22_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_22_2' id='label_5_22_2' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_22_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Rara vez'  id='choice_5_22_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_22_3' id='label_5_22_3' class='gform-field-label gform-field-label--type-inline'>Rara vez<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_22_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Nunca'  id='choice_5_22_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_22_4' id='label_5_22_4' class='gform-field-label gform-field-label--type-inline'>Nunca<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_23\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_23\"><legend class='gfield_label gform-field-label'  >\u00bfToma alg\u00fan suplemento o medicamento?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_23'>\n\t\t\t<div class='gchoice gchoice_5_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Si'  id='choice_5_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_23_0' id='label_5_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_5_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_5_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_23_1' id='label_5_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_24\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_24\"><label class='gfield_label gform-field-label' for='input_5_24' >En caso de un s\u00ed, haga una lista<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_5_24' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_25\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_25\"><legend class='gfield_label gform-field-label'  >\u00bfHace ejercicios, va al gym o practica alg\u00fan deporte?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_25'>\n\t\t\t<div class='gchoice gchoice_5_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Si'  id='choice_5_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_25_0' id='label_5_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_5_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_5_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_25_1' id='label_5_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_25_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='A veces'  id='choice_5_25_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_25_2' id='label_5_25_2' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_26\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_26\"><legend class='gfield_label gform-field-label'  >Le dan antojos fuertes de:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_26'>\n\t\t\t<div class='gchoice gchoice_5_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Az\u00facar'  id='choice_5_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_26_0' id='label_5_26_0' class='gform-field-label gform-field-label--type-inline'>Az\u00facar<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Caf\u00e9'  id='choice_5_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_26_1' id='label_5_26_1' class='gform-field-label gform-field-label--type-inline'>Caf\u00e9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_26_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Cigarrillos'  id='choice_5_26_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_26_2' id='label_5_26_2' class='gform-field-label gform-field-label--type-inline'>Cigarrillos<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_26_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Drogas'  id='choice_5_26_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_26_3' id='label_5_26_3' class='gform-field-label gform-field-label--type-inline'>Drogas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_26_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Todas las anteriores'  id='choice_5_26_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_26_4' id='label_5_26_4' class='gform-field-label gform-field-label--type-inline'>Todas las anteriores<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_26_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Ninguna'  id='choice_5_26_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_26_5' id='label_5_26_5' class='gform-field-label gform-field-label--type-inline'>Ninguna<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_27\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_27\"><legend class='gfield_label gform-field-label'  >\u00bfSu familia o amistades le ayudar\u00edan en su deseo de hacer cambios en su alimentaci\u00f3n y\/o estilo de vida?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_27'>\n\t\t\t<div class='gchoice gchoice_5_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Si'  id='choice_5_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_27_0' id='label_5_27_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_5_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='No'  id='choice_5_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_27_1' id='label_5_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_27_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Tal vez'  id='choice_5_27_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_27_2' id='label_5_27_2' class='gform-field-label gform-field-label--type-inline'>Tal vez<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_28\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_28\"><legend class='gfield_label gform-field-label'  >\u00bfUsted cocina?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_28'>\n\t\t\t<div class='gchoice gchoice_5_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Si'  id='choice_5_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_28_0' id='label_5_28_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_5_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='No'  id='choice_5_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_28_1' id='label_5_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_28_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='A veces'  id='choice_5_28_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_28_2' id='label_5_28_2' class='gform-field-label gform-field-label--type-inline'>A veces<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_29\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_29\"><legend class='gfield_label gform-field-label'  >\u00bfQu\u00e9 porcentaje de su comida esta hecha en casa?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_29'>\n\t\t\t<div class='gchoice gchoice_5_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='0-20%'  id='choice_5_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_29_0' id='label_5_29_0' class='gform-field-label gform-field-label--type-inline'>0-20%<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='20-50%'  id='choice_5_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_29_1' id='label_5_29_1' class='gform-field-label gform-field-label--type-inline'>20-50%<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='50-80%'  id='choice_5_29_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_29_2' id='label_5_29_2' class='gform-field-label gform-field-label--type-inline'>50-80%<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_29_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='80-100%'  id='choice_5_29_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_29_3' id='label_5_29_3' class='gform-field-label gform-field-label--type-inline'>80-100%<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_31\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_31\"><legend class='gfield_label gform-field-label'  >\u00bfEn la escala del 1 al 10 c\u00f3mo es su nivel de energ\u00eda?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_31'>\n\t\t\t<div class='gchoice gchoice_5_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='1'  id='choice_5_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_31_0' id='label_5_31_0' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='2'  id='choice_5_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_31_1' id='label_5_31_1' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_31_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='3'  id='choice_5_31_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_31_2' id='label_5_31_2' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_31_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='4'  id='choice_5_31_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_31_3' id='label_5_31_3' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_31_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='5'  id='choice_5_31_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_31_4' id='label_5_31_4' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_31_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='6'  id='choice_5_31_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_31_5' id='label_5_31_5' class='gform-field-label gform-field-label--type-inline'>6<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_31_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='7'  id='choice_5_31_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_31_6' id='label_5_31_6' class='gform-field-label gform-field-label--type-inline'>7<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_31_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='8'  id='choice_5_31_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_31_7' id='label_5_31_7' class='gform-field-label gform-field-label--type-inline'>8<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_31_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='9'  id='choice_5_31_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_31_8' id='label_5_31_8' class='gform-field-label gform-field-label--type-inline'>9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_31_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='10'  id='choice_5_31_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_31_9' id='label_5_31_9' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_32\"  class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_32\"><label class='gfield_label gform-field-label' for='input_5_32' >Nombre los alimentos que no le gustan o no comer\u00eda nunca<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_5_32' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_33\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_5_33\"><label class='gfield_label gform-field-label' for='input_5_33' >Escriba algo m\u00e1s que quisieras compartir<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_5_33' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div><\/div>\n        <div class='gform_footer before'> <input type='submit' id='gform_submit_button_5' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_5\"]){return false;}  if( !jQuery(\"#gform_5\")[0].checkValidity || jQuery(\"#gform_5\")[0].checkValidity()){window[\"gf_submitting_5\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_5\"]){return false;} if( !jQuery(\"#gform_5\")[0].checkValidity || jQuery(\"#gform_5\")[0].checkValidity()){window[\"gf_submitting_5\"]=true;}  jQuery(\"#gform_5\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' 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