{"id":1999,"date":"2024-10-30T12:22:50","date_gmt":"2024-10-30T12:22:50","guid":{"rendered":"https:\/\/natahuertascosmetologist.com\/?page_id=1999"},"modified":"2024-12-01T00:28:22","modified_gmt":"2024-11-30T13:28:22","slug":"formularios","status":"publish","type":"page","link":"https:\/\/natahuertascosmetologist.com\/en\/formularios\/","title":{"rendered":"COSMETOLOGY CLINICAL SHEET"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1999\" class=\"elementor elementor-1999\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-bb74683 e-flex e-con-boxed e-con e-parent\" data-id=\"bb74683\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-cd4ab71 elementor-widget elementor-widget-heading\" data-id=\"cd4ab71\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">FICHA CLINICA COSMETOLOGA<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-39e05c5 elementor-widget__width-initial elementor-widget elementor-widget-htwpform-addons\" data-id=\"39e05c5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"htwpform-addons.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t            <div class=\"htwpform_area\" >\n                <div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-2010\"><form id=\"wpforms-form-2010\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"2010\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/1999\" data-token=\"f73f5e522cca821584a5b528c5688485\" data-token-time=\"1776605933\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-2010-field_2-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"2\"><fieldset><legend class=\"wpforms-field-label\">FECHA<\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-small\"><select name=\"wpforms[fields][2][date][d]\" id=\"wpforms-2010-field_2-day\" class=\"wpforms-field-date-time-date-day\" aria-label=\"Day\" ><option value=\"\" class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][2][date][m]\" id=\"wpforms-2010-field_2-month\" class=\"wpforms-field-date-time-date-month\" aria-label=\"Month\" ><option value=\"\" class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][2][date][y]\" id=\"wpforms-2010-field_2-year\" class=\"wpforms-field-date-time-date-year\" aria-label=\"Year\" ><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/fieldset><\/div><div id=\"wpforms-2010-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><fieldset><legend class=\"wpforms-field-label\">NOMBRE <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-2010-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" aria-errormessage=\"wpforms-2010-field_1-error\" required><label for=\"wpforms-2010-field_1\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-2010-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" aria-errormessage=\"wpforms-2010-field_1-last-error\" required><label for=\"wpforms-2010-field_1-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-2010-field_18-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"18\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2010-field_5-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_5\">Correo electr\u00f3nico <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-2010-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" spellcheck=\"false\" aria-errormessage=\"wpforms-2010-field_5-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2010-field_4-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_4\">Tel\u00e9fono <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-2010-field_4\" class=\"wpforms-field-small wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][4]\" aria-label=\"Tel\u00e9fono\" aria-errormessage=\"wpforms-2010-field_4-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2010-field_36-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_36\">DIRECCION <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2010-field_36\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][36]\" aria-errormessage=\"wpforms-2010-field_36-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2010-field_19-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"19\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2010-field_148-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"148\"><fieldset><legend class=\"wpforms-field-label\">FECHA DE NACIMIENTO <\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-medium\"><select name=\"wpforms[fields][148][date][m]\" id=\"wpforms-2010-field_148-month\" class=\"wpforms-field-date-time-date-month\" aria-label=\"Month\" ><option value=\"\" class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][148][date][d]\" id=\"wpforms-2010-field_148-day\" class=\"wpforms-field-date-time-date-day\" aria-label=\"Day\" ><option value=\"\" class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][148][date][y]\" id=\"wpforms-2010-field_148-year\" class=\"wpforms-field-date-time-date-year\" aria-label=\"Year\" ><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2010-field_151-container\" class=\"wpforms-field wpforms-field-number-slider\" data-field-id=\"151\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_151\">EDAD<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-2010-field_151\" class=\"wpforms-field-medium\" name=\"wpforms[fields][151]\" value=\"18\" aria-errormessage=\"wpforms-2010-field_151-error\"\t\tmin=\"18\"\n\tmax=\"90\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Valor seleccionado: {value}\">\n\tValor seleccionado: <b>18<\/b><\/div>\n<\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2010-field_145-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"145\"><fieldset><legend class=\"wpforms-field-label\">SEXO<\/legend><ul id=\"wpforms-2010-field_145\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_145_1\" name=\"wpforms[fields][145]\" value=\"MASCULINO\" aria-errormessage=\"wpforms-2010-field_145_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_145_1\">MASCULINO<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_145_2\" name=\"wpforms[fields][145]\" value=\"FEMENINO\" aria-errormessage=\"wpforms-2010-field_145_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_145_2\">FEMENINO<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_145_3\" name=\"wpforms[fields][145]\" value=\"OTRO\" aria-errormessage=\"wpforms-2010-field_145_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_145_3\">OTRO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2010-field_22-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"22\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2010-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_20\">Nombre de un familiar <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2010-field_20\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][20]\" aria-errormessage=\"wpforms-2010-field_20-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2010-field_21-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_21\">Tel\u00e9fono <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-2010-field_21\" class=\"wpforms-field-small wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][21]\" aria-label=\"Tel\u00e9fono\" aria-errormessage=\"wpforms-2010-field_21-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2010-field_25-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"25\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2010-field_28-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_28\">Cuantas horas Duerme <\/label><select id=\"wpforms-2010-field_28\" class=\"wpforms-field-small\" name=\"wpforms[fields][28]\"><option value=\"0\" >0<\/option><option value=\"1 - 4\" >1 - 4<\/option><option value=\"4-7\" >4-7<\/option><option value=\"7 O MAS\" >7 O MAS<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2010-field_24-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_24\">Hace Ejercicio<\/label><select id=\"wpforms-2010-field_24\" class=\"wpforms-field-small\" name=\"wpforms[fields][24]\"><option value=\"SI\" >SI<\/option><option value=\"NO\" >NO<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2010-field_39-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_39\">Como considera su dieta <\/label><select id=\"wpforms-2010-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\"><option value=\"MALA\" >MALA<\/option><option value=\"BUENA\"  selected='selected'>BUENA<\/option><option value=\"EXCELENTE\" >EXCELENTE<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2010-field_38-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"38\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_31-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_31\">En promedio Cuantas horas esta expuesta al sol cada dia <\/label><select id=\"wpforms-2010-field_31\" class=\"wpforms-field-small\" name=\"wpforms[fields][31]\"><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"TODO EL DIA\" >TODO EL DIA<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_33-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_33\">USO PROTECTOR SOLAR <\/label><select id=\"wpforms-2010-field_33\" class=\"wpforms-field-small\" name=\"wpforms[fields][33]\"><option value=\"SI\" >SI<\/option><option value=\"NO\" >NO<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_34-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_34\">REAPLICABLE<\/label><select id=\"wpforms-2010-field_34\" class=\"wpforms-field-small\" name=\"wpforms[fields][34]\"><option value=\"SI\" >SI<\/option><option value=\"NO\" >NO<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_153-container\" class=\"wpforms-field wpforms-field-number-slider\" data-field-id=\"153\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_153\">CANTIDAD DE AGUA QUE TOMA AL DIA (LITROS)<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-2010-field_153\" class=\"wpforms-field-medium\" name=\"wpforms[fields][153]\" value=\"0\" aria-errormessage=\"wpforms-2010-field_153-error\"\t\tmin=\"0\"\n\tmax=\"4\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Valor seleccionado: {value}\">\n\tValor seleccionado: <b>0<\/b><\/div>\n<\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2010-field_43-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"43\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tESCALA DE 1 AL 5 FRECUENCIA DE CONSUMO\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_42-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_42\">AZUCARES<\/label><select id=\"wpforms-2010-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\"><option value=\"0\" >0<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_45-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_45\">LACTEOS<\/label><select id=\"wpforms-2010-field_45\" class=\"wpforms-field-medium\" name=\"wpforms[fields][45]\"><option value=\"0\" >0<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_46-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_46\">FRUTAS<\/label><select id=\"wpforms-2010-field_46\" class=\"wpforms-field-medium\" name=\"wpforms[fields][46]\"><option value=\"0\" >0<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_47-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_47\">VERDURAS<\/label><select id=\"wpforms-2010-field_47\" class=\"wpforms-field-medium\" name=\"wpforms[fields][47]\"><option value=\"0\" >0<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_48-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_48\">CARNES ROJAS<\/label><select id=\"wpforms-2010-field_48\" class=\"wpforms-field-medium\" name=\"wpforms[fields][48]\"><option value=\"0\" >0<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_51-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_51\">CARNES BLANCAS <\/label><select id=\"wpforms-2010-field_51\" class=\"wpforms-field-medium\" name=\"wpforms[fields][51]\"><option value=\"0\" >0<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_50-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_50\">HARINAS<\/label><select id=\"wpforms-2010-field_50\" class=\"wpforms-field-medium\" name=\"wpforms[fields][50]\"><option value=\"0\" >0<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_49-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_49\">GRASAS<\/label><select id=\"wpforms-2010-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\"><option value=\"0\" >0<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2010-field_62-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"62\"><\/div><div id=\"wpforms-2010-field_53-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"53\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_54-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_54\">VITAMINAS <\/label><select id=\"wpforms-2010-field_54\" class=\"wpforms-field-medium\" name=\"wpforms[fields][54]\"><option value=\"SI\" >SI<\/option><option value=\"NO\" >NO<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_55-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_55\">ANTICONCEPTIVOS<\/label><select id=\"wpforms-2010-field_55\" class=\"wpforms-field-medium\" name=\"wpforms[fields][55]\"><option value=\"SI\" >SI<\/option><option value=\"NO\" >NO<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_56-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_56\">MEDICAMENTOS<\/label><select id=\"wpforms-2010-field_56\" class=\"wpforms-field-medium\" name=\"wpforms[fields][56]\"><option value=\"SI\" >SI<\/option><option value=\"NO\" >NO<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_57-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_57\">OTRAS HORMONAS<\/label><select id=\"wpforms-2010-field_57\" class=\"wpforms-field-medium\" name=\"wpforms[fields][57]\"><option value=\"SI\" >SI<\/option><option value=\"NO\" >NO<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_58-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_58\">ESCRIBA CUALES<\/label><input type=\"text\" id=\"wpforms-2010-field_58\" class=\"wpforms-field-medium\" name=\"wpforms[fields][58]\" aria-errormessage=\"wpforms-2010-field_58-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_59-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_59\">ESCRIBA CUALES<\/label><input type=\"text\" id=\"wpforms-2010-field_59\" class=\"wpforms-field-medium\" name=\"wpforms[fields][59]\" aria-errormessage=\"wpforms-2010-field_59-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_60-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_60\">ESCRIBA CUALES<\/label><input type=\"text\" id=\"wpforms-2010-field_60\" class=\"wpforms-field-medium\" name=\"wpforms[fields][60]\" aria-errormessage=\"wpforms-2010-field_60-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_61-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_61\">ESCRIBA CUALES<\/label><input type=\"text\" id=\"wpforms-2010-field_61\" class=\"wpforms-field-medium\" name=\"wpforms[fields][61]\" aria-errormessage=\"wpforms-2010-field_61-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2010-field_65-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"65\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_66-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"66\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_66\">EMBARAZO<\/label><select id=\"wpforms-2010-field_66\" class=\"wpforms-field-medium\" name=\"wpforms[fields][66]\"><option value=\"SI\" >SI<\/option><option value=\"NO\" >NO<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_68-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"68\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_68\">HIJOS<\/label><select id=\"wpforms-2010-field_68\" class=\"wpforms-field-medium\" name=\"wpforms[fields][68]\"><option value=\"SI\" >SI<\/option><option value=\"NO\" >NO<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_70-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_70\">PARTOS<\/label><select id=\"wpforms-2010-field_70\" class=\"wpforms-field-medium\" name=\"wpforms[fields][70]\"><option value=\"SI\" >SI<\/option><option value=\"NO\" >NO<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_79-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"79\"><fieldset><legend class=\"wpforms-field-label\">ABORTOS<\/legend><ul id=\"wpforms-2010-field_79\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_79_1\" name=\"wpforms[fields][79]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_79_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_79_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_79_2\" name=\"wpforms[fields][79]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_79_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_79_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_80-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"80\"><fieldset><legend class=\"wpforms-field-label\">LACTANCIA MATERA<\/legend><ul id=\"wpforms-2010-field_80\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_80_1\" name=\"wpforms[fields][80]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_80_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_80_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_80_2\" name=\"wpforms[fields][80]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_80_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_80_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_81-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"81\"><fieldset><legend class=\"wpforms-field-label\">CICLO MESTRUAL<\/legend><ul id=\"wpforms-2010-field_81\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_81_1\" name=\"wpforms[fields][81]\" value=\"REGULAR\" aria-errormessage=\"wpforms-2010-field_81_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_81_1\">REGULAR<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_81_2\" name=\"wpforms[fields][81]\" value=\"IRREGULAR\" aria-errormessage=\"wpforms-2010-field_81_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_81_2\">IRREGULAR<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><\/div><\/div><\/div><div id=\"wpforms-2010-field_83-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"83\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_83\">Ha presentado o presenta alteraciones  hormonales ?<\/label><textarea id=\"wpforms-2010-field_83\" class=\"wpforms-field-small\" name=\"wpforms[fields][83]\" aria-errormessage=\"wpforms-2010-field_83-error\" ><\/textarea><\/div><div id=\"wpforms-2010-field_86-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"86\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2010-field_85-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"85\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_85\">Fobias , colbulsiones o alergias ?<\/label><textarea id=\"wpforms-2010-field_85\" class=\"wpforms-field-small\" name=\"wpforms[fields][85]\" aria-errormessage=\"wpforms-2010-field_85-error\" ><\/textarea><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2010-field_88-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"88\"><fieldset><legend class=\"wpforms-field-label\">Implantes o dispositivos<\/legend><ul id=\"wpforms-2010-field_88\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2010-field_88_1\" name=\"wpforms[fields][88][]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_88_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_88_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2010-field_88_2\" name=\"wpforms[fields][88][]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_88_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_88_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2010-field_89-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"89\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-50-25\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-2010-field_91-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"91\"><fieldset><legend class=\"wpforms-field-label\">MOTIVO DE CONSULTA<\/legend><ul id=\"wpforms-2010-field_91\" class=\"wpforms-randomize\" data-choice-limit=\"2\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2010-field_91_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][91][]\" value=\"ENVEJECIMIENTO\" aria-errormessage=\"wpforms-2010-field_91_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_91_1\">ENVEJECIMIENTO<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2010-field_91_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][91][]\" value=\"ARRUGAS\" aria-errormessage=\"wpforms-2010-field_91_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_91_2\">ARRUGAS<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-2010-field_91_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][91][]\" value=\"MANCHAS\" aria-errormessage=\"wpforms-2010-field_91_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_91_4\">MANCHAS<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-2010-field_91_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][91][]\" value=\"ACNE\" aria-errormessage=\"wpforms-2010-field_91_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_91_5\">ACNE<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-2010-field_91_6\" data-rule-check-limit=\"true\" name=\"wpforms[fields][91][]\" value=\"ROSACEA\" aria-errormessage=\"wpforms-2010-field_91_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_91_6\">ROSACEA<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-2010-field_91_7\" data-rule-check-limit=\"true\" name=\"wpforms[fields][91][]\" value=\"FLACIDEZ\" aria-errormessage=\"wpforms-2010-field_91_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_91_7\">FLACIDEZ<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-2010-field_91_8\" data-rule-check-limit=\"true\" name=\"wpforms[fields][91][]\" value=\"CUIDADO DE LA PIEL\" aria-errormessage=\"wpforms-2010-field_91_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_91_8\">CUIDADO DE LA PIEL<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-2010-field_91_9\" data-rule-check-limit=\"true\" name=\"wpforms[fields][91][]\" value=\"OTRO\" aria-errormessage=\"wpforms-2010-field_91_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_91_9\">OTRO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-2010-field_92-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"92\"><fieldset><legend class=\"wpforms-field-label\">SE HA REALIZADO TRATAMIENTO PARA ESTE PROBLEMA <\/legend><ul id=\"wpforms-2010-field_92\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_92_1\" name=\"wpforms[fields][92]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_92_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_92_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_92_2\" name=\"wpforms[fields][92]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_92_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_92_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2010-field_95-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"95\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_95\">LE  HA DADO RESULTADO?<\/label><select id=\"wpforms-2010-field_95\" class=\"wpforms-field-medium\" name=\"wpforms[fields][95]\"><option value=\"SI\" >SI<\/option><option value=\"NO\" >NO<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-2010-field_96-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"96\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_96\">Hace cuanto se lo realizo?<\/label><select id=\"wpforms-2010-field_96\" class=\"wpforms-field-medium\" name=\"wpforms[fields][96]\"><option value=\"1-12 meses\" >1-12 meses<\/option><option value=\"1-3  A\u00f1os\" >1-3  A\u00f1os<\/option><option value=\"Mas de 3 a\u00f1os\" >Mas de 3 a\u00f1os<\/option><\/select><\/div><\/div><\/div><\/div><div id=\"wpforms-2010-field_111-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"111\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tPRODUCTOS  QUE UTILIZA EN CASA \n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2010-field_106-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"106\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_106\">1<\/label><input type=\"text\" id=\"wpforms-2010-field_106\" class=\"wpforms-field-small\" name=\"wpforms[fields][106]\" aria-errormessage=\"wpforms-2010-field_106-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2010-field_112-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"112\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_112\">2<\/label><input type=\"text\" id=\"wpforms-2010-field_112\" class=\"wpforms-field-small\" name=\"wpforms[fields][112]\" aria-errormessage=\"wpforms-2010-field_112-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2010-field_115-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"115\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_115\">3<\/label><input type=\"text\" id=\"wpforms-2010-field_115\" class=\"wpforms-field-small\" name=\"wpforms[fields][115]\" aria-errormessage=\"wpforms-2010-field_115-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2010-field_118-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"118\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tAPARATOLOGIA \/ HERRAMIENTA A UTILIZAR\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2010-field_119-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"119\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_119\">1<\/label><input type=\"text\" id=\"wpforms-2010-field_119\" class=\"wpforms-field-medium\" name=\"wpforms[fields][119]\" aria-errormessage=\"wpforms-2010-field_119-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2010-field_120-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"120\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_120\">2<\/label><input type=\"text\" id=\"wpforms-2010-field_120\" class=\"wpforms-field-medium\" name=\"wpforms[fields][120]\" aria-errormessage=\"wpforms-2010-field_120-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2010-field_122-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"122\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_122\">TRATAMIENTO A REALIZAR <\/label><textarea id=\"wpforms-2010-field_122\" class=\"wpforms-field-medium\" name=\"wpforms[fields][122]\" aria-errormessage=\"wpforms-2010-field_122-error\" ><\/textarea><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2010-field_154-container\" class=\"wpforms-field wpforms-field-number-slider\" data-field-id=\"154\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_154\">CUANTAS SESIONES ?<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-2010-field_154\" class=\"wpforms-field-medium\" name=\"wpforms[fields][154]\" value=\"0\" aria-errormessage=\"wpforms-2010-field_154-error\"\t\tmin=\"0\"\n\tmax=\"10\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Valor seleccionado: {value}\">\n\tValor seleccionado: <b>0<\/b><\/div>\n<\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2010-field_124-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"124\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_124\">ME COMPROMETO A <\/label><textarea id=\"wpforms-2010-field_124\" class=\"wpforms-field-medium\" name=\"wpforms[fields][124]\" aria-errormessage=\"wpforms-2010-field_124-error\" ><\/textarea><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2010-field_125-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"125\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_125\">OBSERVACIONES<\/label><textarea id=\"wpforms-2010-field_125\" class=\"wpforms-field-medium\" name=\"wpforms[fields][125]\" aria-errormessage=\"wpforms-2010-field_125-error\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2010-field_160-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"160\"><\/div><div id=\"wpforms-2010-field_159-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"159\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_161-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"161\"><fieldset><legend class=\"wpforms-field-label\">Hipertension Arterial<\/legend><ul id=\"wpforms-2010-field_161\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_161_1\" name=\"wpforms[fields][161]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_161_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_161_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_161_2\" name=\"wpforms[fields][161]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_161_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_161_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_162-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"162\"><fieldset><legend class=\"wpforms-field-label\">Colesterol<\/legend><ul id=\"wpforms-2010-field_162\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_162_1\" name=\"wpforms[fields][162]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_162_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_162_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_162_2\" name=\"wpforms[fields][162]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_162_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_162_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_163-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"163\"><fieldset><legend class=\"wpforms-field-label\">Diabetes<\/legend><ul id=\"wpforms-2010-field_163\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_163_1\" name=\"wpforms[fields][163]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_163_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_163_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_163_2\" name=\"wpforms[fields][163]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_163_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_163_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_164-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"164\"><fieldset><legend class=\"wpforms-field-label\">Alergias<\/legend><ul id=\"wpforms-2010-field_164\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_164_1\" name=\"wpforms[fields][164]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_164_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_164_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_164_2\" name=\"wpforms[fields][164]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_164_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_164_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_165-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"165\"><fieldset><legend class=\"wpforms-field-label\">Disfunsion Hormonal<\/legend><ul id=\"wpforms-2010-field_165\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_165_1\" name=\"wpforms[fields][165]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_165_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_165_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_165_2\" name=\"wpforms[fields][165]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_165_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_165_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_166-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"166\"><fieldset><legend class=\"wpforms-field-label\">Implantes<\/legend><ul id=\"wpforms-2010-field_166\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_166_1\" name=\"wpforms[fields][166]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_166_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_166_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_166_2\" name=\"wpforms[fields][166]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_166_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_166_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_167-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"167\"><fieldset><legend class=\"wpforms-field-label\">Cirugias \/ Cicatrizacion<\/legend><ul id=\"wpforms-2010-field_167\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_167_1\" name=\"wpforms[fields][167]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_167_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_167_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_167_2\" name=\"wpforms[fields][167]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_167_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_167_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_168-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"168\"><fieldset><legend class=\"wpforms-field-label\">Menstruacion<\/legend><ul id=\"wpforms-2010-field_168\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_168_1\" name=\"wpforms[fields][168]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_168_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_168_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_168_2\" name=\"wpforms[fields][168]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_168_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_168_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_169-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"169\"><fieldset><legend class=\"wpforms-field-label\">Antecedentes enermedades piel<\/legend><ul id=\"wpforms-2010-field_169\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_169_1\" name=\"wpforms[fields][169]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_169_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_169_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_169_2\" name=\"wpforms[fields][169]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_169_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_169_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_170-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"170\"><fieldset><legend class=\"wpforms-field-label\">Caida del cabello<\/legend><ul id=\"wpforms-2010-field_170\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_170_1\" name=\"wpforms[fields][170]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_170_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_170_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_170_2\" name=\"wpforms[fields][170]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_170_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_170_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_171-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"171\"><fieldset><legend class=\"wpforms-field-label\">Portador de marcapasos<\/legend><ul id=\"wpforms-2010-field_171\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_171_1\" name=\"wpforms[fields][171]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_171_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_171_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_171_2\" name=\"wpforms[fields][171]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_171_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_171_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_172-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"172\"><fieldset><legend class=\"wpforms-field-label\">Protesis metalicas<\/legend><ul id=\"wpforms-2010-field_172\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_172_1\" name=\"wpforms[fields][172]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_172_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_172_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_172_2\" name=\"wpforms[fields][172]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_172_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_172_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_174-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"174\"><fieldset><legend class=\"wpforms-field-label\">Lentes de contacto<\/legend><ul id=\"wpforms-2010-field_174\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_174_1\" name=\"wpforms[fields][174]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_174_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_174_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_174_2\" name=\"wpforms[fields][174]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_174_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_174_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_175-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"175\"><fieldset><legend class=\"wpforms-field-label\">Antecedentes oncologicos<\/legend><ul id=\"wpforms-2010-field_175\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_175_1\" name=\"wpforms[fields][175]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_175_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_175_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_175_2\" name=\"wpforms[fields][175]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_175_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_175_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_176-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"176\"><fieldset><legend class=\"wpforms-field-label\">Herpes labiales<\/legend><ul id=\"wpforms-2010-field_176\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_176_1\" name=\"wpforms[fields][176]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_176_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_176_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_176_2\" name=\"wpforms[fields][176]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_176_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_176_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_177-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"177\"><fieldset><legend class=\"wpforms-field-label\">Varices<\/legend><ul id=\"wpforms-2010-field_177\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_177_1\" name=\"wpforms[fields][177]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_177_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_177_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_177_2\" name=\"wpforms[fields][177]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_177_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_177_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_178-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"178\"><fieldset><legend class=\"wpforms-field-label\">Fobias<\/legend><ul id=\"wpforms-2010-field_178\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_178_1\" name=\"wpforms[fields][178]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_178_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_178_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_178_2\" name=\"wpforms[fields][178]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_178_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_178_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_179-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"179\"><fieldset><legend class=\"wpforms-field-label\">Convulsiones<\/legend><ul id=\"wpforms-2010-field_179\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_179_1\" name=\"wpforms[fields][179]\" value=\"SI\" aria-errormessage=\"wpforms-2010-field_179_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_179_1\">SI<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2010-field_179_2\" name=\"wpforms[fields][179]\" value=\"NO\" aria-errormessage=\"wpforms-2010-field_179_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_179_2\">NO<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2010-field_180-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"180\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_180\">OTROS<\/label><textarea id=\"wpforms-2010-field_180\" class=\"wpforms-field-medium\" name=\"wpforms[fields][180]\" aria-errormessage=\"wpforms-2010-field_180-error\" ><\/textarea><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><\/div><\/div><\/div><div id=\"wpforms-2010-field_173-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"173\"><\/div><div id=\"wpforms-2010-field_129-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"129\"><fieldset><legend class=\"wpforms-field-label\">AUTORIZA QUE LA COSMETOLOGA TOME FOTOGRAFIAS CONFIDENCIALES DE PROCEDIMIENTO ESTETICOCON EL UNICO FIN DE OBSERVAR LOS RESULTADOS Y EL AVANCE DE SU TRATAMIENTO. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2010-field_129\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2010-field_129_1\" name=\"wpforms[fields][129][]\" value=\"SI AUTORIZO\" aria-errormessage=\"wpforms-2010-field_129_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_129_1\">SI AUTORIZO<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2010-field_129_2\" name=\"wpforms[fields][129][]\" value=\"NO AUTORIZO\" aria-errormessage=\"wpforms-2010-field_129_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_129_2\">NO AUTORIZO<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2010-field_130-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"130\"><fieldset><legend class=\"wpforms-field-label\">DE IGUAL MANERA, AUTORIZO QUE SUS FOTOGRAFIAS SEAN PUBLICADAS EN REDES SOCIALES SOLO MOSTRANDOLA ZONA TRABAJADA, CON LA FINALIDAD DE HACER PUBLICIDAD A LA COSMETOLOGA  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2010-field_130\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2010-field_130_1\" name=\"wpforms[fields][130][]\" value=\"SI ACEPTO\" aria-errormessage=\"wpforms-2010-field_130_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_130_1\">SI ACEPTO<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2010-field_130_2\" name=\"wpforms[fields][130][]\" value=\"NO ACEPTO\" aria-errormessage=\"wpforms-2010-field_130_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2010-field_130_2\">NO ACEPTO<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2010-field_155-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"155\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-67\"><div id=\"wpforms-2010-field_131-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"131\"><fieldset><legend class=\"wpforms-field-label\">YO  CERTIFICO QUE HE ENTENDIDO CLARAMENTE LA EXPLICACION SOBRE LOS TRATAMIENTOS, APLICACION Y SUS POSIBLES EFECTOS SECUNDARIOS , POR LO CUAL ASUMO LA RESPONSABILIDAD QUE TENGO COMO PACIENTE PARA EL EXITO DE ESTE , ASI MISMO LOS CUIDADOS QUE DEBO TENER EN  CASA O FUERA DEL SPA  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-2010-field_131\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][131][first]\" aria-errormessage=\"wpforms-2010-field_131-error\" required><label for=\"wpforms-2010-field_131\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-2010-field_131-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][131][last]\" aria-errormessage=\"wpforms-2010-field_131-last-error\" required><label for=\"wpforms-2010-field_131-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2010-field_156-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"156\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_156\">        Firma<\/label><div class=\"wpforms-signature-wrap wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-2010-field_156-signature\" data-color=\"#000000\"><\/canvas><button class=\"wpforms-signature-clear\" title=\"Clear Signature\">Clear Signature<\/button><\/div><input type=\"text\" id=\"wpforms-2010-field_156\" class=\"wpforms-signature-input wpforms-screen-reader-element\" name=\"wpforms[fields][156]\" aria-errormessage=\"wpforms-2010-field_156-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2010-field_181-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"181\"><label class=\"wpforms-field-label\" for=\"wpforms-2010-field_181\">Firma<\/label><div class=\"wpforms-signature-wrap wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-2010-field_181-signature\" data-color=\"#000000\"><\/canvas><button class=\"wpforms-signature-clear\" title=\"Clear Signature\">Clear Signature<\/button><\/div><input type=\"text\" id=\"wpforms-2010-field_181\" class=\"wpforms-signature-input wpforms-screen-reader-element\" name=\"wpforms[fields][181]\" aria-errormessage=\"wpforms-2010-field_181-error\" ><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v3\" ><input type=\"hidden\" name=\"wpforms[recaptcha]\" value=\"\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"2010\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/natahuertascosmetologist.com\/en\/wp-json\/wp\/v2\/pages\/1999\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-2010\" class=\"wpforms-submit\" data-alt-text=\"Enviando...\" data-submit-text=\"Enviar\" aria-live=\"assertive\" value=\"wpforms-submit\">Enviar<\/button><img decoding=\"async\" src=\"https:\/\/natahuertascosmetologist.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->            <\/div>\n\n        \t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>FICHA CLINICA COSMETOLOGA Por favor, activa JavaScript en tu navegador para completar este formulario.Por favor, activa JavaScript en tu navegador para completar este formulario. FECHA DD12345678910111213141516171819202122232425262728293031MM123456789101112AAAA2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 NOMBRE * NombreApellidos Correo electr\u00f3nico *Tel\u00e9fono *DIRECCION * FECHA DE NACIMIENTO MM123456789101112DD12345678910111213141516171819202122232425262728293031AAAA2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 EDAD Valor seleccionado: 18 SEXO MASCULINO FEMENINO OTRO Nombre de un familiar *Tel\u00e9fono *Cuantas horas Duerme 01 [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1999","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/natahuertascosmetologist.com\/en\/wp-json\/wp\/v2\/pages\/1999","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/natahuertascosmetologist.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/natahuertascosmetologist.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/natahuertascosmetologist.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/natahuertascosmetologist.com\/en\/wp-json\/wp\/v2\/comments?post=1999"}],"version-history":[{"count":74,"href":"https:\/\/natahuertascosmetologist.com\/en\/wp-json\/wp\/v2\/pages\/1999\/revisions"}],"predecessor-version":[{"id":2764,"href":"https:\/\/natahuertascosmetologist.com\/en\/wp-json\/wp\/v2\/pages\/1999\/revisions\/2764"}],"wp:attachment":[{"href":"https:\/\/natahuertascosmetologist.com\/en\/wp-json\/wp\/v2\/media?parent=1999"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}