{"id":165,"date":"2020-09-22T20:40:30","date_gmt":"2020-09-22T20:40:30","guid":{"rendered":"http:\/\/osaverdeymar.com\/?page_id=165"},"modified":"2022-08-01T01:52:08","modified_gmt":"2022-08-01T01:52:08","slug":"segmento-wellness","status":"publish","type":"page","link":"http:\/\/osaverdeymar.com\/?page_id=165","title":{"rendered":"Segmento Wellness"},"content":{"rendered":"\n<section id=\"section-e8ff90e8-a666-4f93-9e82-59d0348111c5\" class=\"wp-block-gutentor-image-slider gutentor-section gutentor-image-slider imageSlider-template1\"><div class=\"gutentor-grid-item-wrap\"><div class=\"gutentor-slider-wrapper\" data-dots=\"true\" data-arrows=\"true\" data-infinite=\"true\" data-nextarrow=\"fas fa-angle-right\" data-prevarrow=\"fas fa-angle-left\" data-autoplay=\"true\" data-autoplayspeed=\"7000\" data-fade=\"false\" data-speed=\"900\"><div class=\"gutentor-slider-item\"><div class=\"gutentor-single-item gutentor-single-item-0\"><div class=\"gutentor-single-item-wrap\"><div class=\"gutentor-single-item-image-box\"><div class=\"gutentor-bg-image\"><div class=\"overlay\"><\/div><\/div><\/div><div class=\"gutentor-single-item-content\"><div class=\"grid-container\"><div class=\"slider-caption text-center\"><h3 class=\"gutentor-single-item-title\">Mejora tu Estilo de Vida<\/h3><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"gutentor-slider-item\"><div class=\"gutentor-single-item gutentor-single-item-1\"><div class=\"gutentor-single-item-wrap\"><div class=\"gutentor-single-item-image-box\"><div class=\"gutentor-bg-image\"><div class=\"overlay\"><\/div><\/div><\/div><div class=\"gutentor-single-item-content\"><div class=\"grid-container\"><div class=\"slider-caption text-center\"><h3 class=\"gutentor-single-item-title\">Programa Wellness<\/h3><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"gutentor-slider-item\"><div class=\"gutentor-single-item gutentor-single-item-2\"><div class=\"gutentor-single-item-wrap\"><div class=\"gutentor-single-item-image-box\"><div class=\"gutentor-bg-image\"><div class=\"overlay\"><\/div><\/div><\/div><div class=\"gutentor-single-item-content\"><div class=\"grid-container\"><div class=\"slider-caption text-center\"><h3 class=\"gutentor-single-item-title\"><strong>Salud y Bienestar<\/strong><\/h3><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/section>\n\n\n\n<div style=\"height:100px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<div id=\"section-g6d88c3\" class=\"wp-block-gutentor-e0 section-g6d88c3 gutentor-element gutentor-element-advanced-text text-align-center-desktop\"><div class=\"gutentor-text-wrap\"><h2 class=\"gutentor-text\">Turismo Wellness<\/h2><\/div><\/div>\n\n\n\n<div style=\"height:100px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-8f761849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:10.4%\"><\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:70%\">\n<div id=\"section-gbae76b\" class=\"wp-block-gutentor-e0 section-gbae76b gutentor-element gutentor-element-advanced-text\"><div class=\"gutentor-text-wrap\"><p class=\"gutentor-text\">Este programa es ideal para quienes quieren empezar a llevar un mejor estilo de vida, o para quienes ya tienen un estilo de vida saludable.<br><br>Asesorados por nuestra nutricionista y por nuestra entrenadora f\u00edsica, hemos dise\u00f1ado este programa para que lleven un men\u00fa saludable con comidas fuertes y meriendas en el horario recomendado, combinadas con una serie de actividades f\u00edsicas mientras conoce y explora nuestro bello pa\u00eds y todas las maravillas naturales que tiene para ofrecer.<br><br>Este recorrido de 11 d\u00edas y 10 noches incluye recorridos, transporte, alojamiento, comidas y meriendas.<br><br>*You may find all the information available in English once you download the PDF with the detailed program. You can download it by clicking on the &#8220;+INFO&#8221; button. <\/p><\/div><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:10.4%\"><\/div>\n<\/div>\n\n\n\n<div style=\"height:100px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-8f761849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:10.4%\"><\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:25.9%\">\n<div id=\"section-g33811d\" class=\"wp-block-gutentor-e0 section-g33811d gutentor-element gutentor-element-advanced-text\"><div class=\"gutentor-text-wrap\"><h3 class=\"gutentor-text\">Descripci\u00f3n del Programa<\/h3><\/div><\/div>\n\n\n\n<div id=\"section-ga36deb\" class=\"wp-block-gutentor-e0 section-ga36deb gutentor-element gutentor-element-advanced-text\"><div class=\"gutentor-text-wrap\"><p class=\"gutentor-text\">Este paquete tiene una duraci\u00f3n de 11 d\u00edas y 10 noches.<br><br>Funciona a partir de 10 participantes. <br><br><\/p><\/div><\/div>\n\n\n\n<div class=\"wp-block-file\"><a href=\"https:\/\/osaverdeymar.com\/wp-content\/uploads\/2022\/05\/Obesos-Nutricion-PilatesREV2-1.pdf\" class=\"wp-block-file__button\" download aria-describedby=\"wp-block-file--media-8ad6e764-e706-46f1-bc58-bf7ed3a37b9b\">+INFO<\/a><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:45.2%\">\n\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:10.4%\"><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"634\" height=\"203\" src=\"http:\/\/osaverdeymar.com\/wp-content\/uploads\/2022\/02\/Untitled-1-2.jpg\" alt=\"\" class=\"wp-image-508\" srcset=\"http:\/\/osaverdeymar.com\/wp-content\/uploads\/2022\/02\/Untitled-1-2.jpg 634w, http:\/\/osaverdeymar.com\/wp-content\/uploads\/2022\/02\/Untitled-1-2-300x96.jpg 300w\" sizes=\"auto, (max-width: 634px) 100vw, 634px\" \/><\/figure><\/div>\n\n\n\n<p class=\"wp-block-paragraph\"> <\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><strong>Expediente de Salud<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\">Por favor complete este formulario y en breve le daremos una respuesta.<\/p>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-8f761849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:10%\"><\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:70%\">\n<div class=\"forminator-guttenberg\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-615   forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-615\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-615\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-615   forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"615\"\n\t\t\t\t\n\t\t\t\tdata-design=\"none\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\tenctype=\"multipart\/form-data\"\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t><div class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Informaci\u00f3n personal<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1\" class=\"forminator-label\">Pa\u00eds<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-2\" class=\"forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2\" class=\"forminator-label\">Estado<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1\" class=\"forminator-label\">Nombre<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"select-1\" class=\"forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-1-label\" class=\"forminator-label\">Sexo<\/label><select id=\"forminator-form-615__field--select-1\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-1\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"M\"  data-calculation=\"0\">M<\/option><option value=\"F\"  data-calculation=\"0\">F<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-1\" class=\"forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-1\" class=\"forminator-label\">Edad<\/label><input name=\"number-1\" value=\"\" placeholder=\"\" id=\"forminator-field-number-1\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"'groupSeparator': '', 'radixPoint': '', 'digits': '0'\" type=\"number\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker-6a2d9730180a9\" class=\"forminator-label\">Fecha de nacimiento<\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-1-picker-6a2d9730180a9\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-picker-6a2d9730180a9\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"number-2\" class=\"forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-2\" class=\"forminator-label\">N\u00famero de identificaci\u00f3n<\/label><input name=\"number-2\" value=\"\" placeholder=\"\" id=\"forminator-field-number-2\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"'groupSeparator': '', 'radixPoint': '', 'digits': '0'\" type=\"number\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3\" class=\"forminator-label\">Ocupaci\u00f3n<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1\" class=\"forminator-label\">Tel\u00e9fono<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1\" class=\"forminator-label\">Direcci\u00f3n electr\u00f3nica<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Estado funcional<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Es independiente para realizar actividades b\u00e1sicas como:<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-2\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-2-label\" class=\"forminator-label\">Caminar<\/label><select id=\"forminator-form-615__field--select-2\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-2\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-3\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-3-label\" class=\"forminator-label\">Lavarse las manos<\/label><select id=\"forminator-form-615__field--select-3\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-3\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-4\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-4-label\" class=\"forminator-label\">Ir al ba\u00f1o<\/label><select id=\"forminator-form-615__field--select-4\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-4\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-2\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Instrumentales<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-5\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-5-label\" class=\"forminator-label\">\u00bfCognitivamente procesa la informaci\u00f3n, uso de memoria, atenci\u00f3n, percepci\u00f3n, creatividad, realiza c\u00e1lculos?<\/label><select id=\"forminator-form-615__field--select-5\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-5\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-3\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Dispositivos m\u00e9dicos<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-6\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-6-label\" class=\"forminator-label\">\u00bfUsa sonda Foley?<\/label><select id=\"forminator-form-615__field--select-6\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-6\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-7\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-7-label\" class=\"forminator-label\">\u00bfRequiere Ox\u00edgeno?<\/label><select id=\"forminator-form-615__field--select-7\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-7\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-8\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-8-label\" class=\"forminator-label\">\u00bfUsa marcapasos card\u00edaco?<\/label><select id=\"forminator-form-615__field--select-8\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-8\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-14\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-14-label\" class=\"forminator-label\">\u00bfOtros?<\/label><select id=\"forminator-form-615__field--select-14\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-14\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1\" class=\"forminator-label\">\u00bfCu\u00e1les?<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-4\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Padecimientos cr\u00f3nicos<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-10\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-10-label\" class=\"forminator-label\">Hipertensi\u00f3n arterial<\/label><select id=\"forminator-form-615__field--select-10\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-10\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-11\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-11-label\" class=\"forminator-label\">Diabetes<\/label><select id=\"forminator-form-615__field--select-11\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-11\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-12\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-12-label\" class=\"forminator-label\">EPOC<\/label><select id=\"forminator-form-615__field--select-12\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-12\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-13\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-13-label\" class=\"forminator-label\">\u00bfOtros?<\/label><select id=\"forminator-form-615__field--select-13\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-13\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2\" class=\"forminator-label\">\u00bfCu\u00e1les?<\/label><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-5\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Tratamientos cr\u00f3nicos<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-3\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3\" class=\"forminator-label\">Nombre del o los medicamentos, horarios y dosis:<\/label><textarea name=\"textarea-3\" placeholder=\"\" id=\"forminator-field-textarea-3\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-4\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4\" class=\"forminator-label\">Insulina<\/label><textarea name=\"textarea-4\" placeholder=\"\" id=\"forminator-field-textarea-4\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-6\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Alerg\u00edas a medicamentos<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-5\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-5\" class=\"forminator-label\">Detalle<\/label><textarea name=\"textarea-5\" placeholder=\"\" id=\"forminator-field-textarea-5\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-7\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Esquema de vacunaci\u00f3n: Vacunaci\u00f3n normal de la infancia (es muy frecuente ver en los extranjeros los movimientos anti-vacunas, requerimos por prevenci\u00f3n saber si tienen o no los esquemas de vacunaci\u00f3n.<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-15\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-15-label\" class=\"forminator-label\">Varicela<\/label><select id=\"forminator-form-615__field--select-15\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-15\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-16\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-16-label\" class=\"forminator-label\">Sarampi\u00f3n<\/label><select id=\"forminator-form-615__field--select-16\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-16\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-17\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-17-label\" class=\"forminator-label\">Rubiola<\/label><select id=\"forminator-form-615__field--select-17\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-17\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-18\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-18-label\" class=\"forminator-label\">Paperas<\/label><select id=\"forminator-form-615__field--select-18\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-18\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-8\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Seg\u00fan regi\u00f3n de procedencia:<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-19\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-19-label\" class=\"forminator-label\">Si es de Suram\u00e9rica, fiebre amarilla<\/label><select id=\"forminator-form-615__field--select-19\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-19\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-9\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">COVID<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-6\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-6\" class=\"forminator-label\">Casa farmac\u00e9utica<\/label><textarea name=\"textarea-6\" placeholder=\"\" id=\"forminator-field-textarea-6\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-7\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-7\" class=\"forminator-label\">Fechas aproximadas<\/label><textarea name=\"textarea-7\" placeholder=\"\" id=\"forminator-field-textarea-7\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-3\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-3\" class=\"forminator-label\">Cantidad de dosis<\/label><input name=\"number-3\" value=\"\" placeholder=\"\" id=\"forminator-field-number-3\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"'groupSeparator': '', 'radixPoint': '', 'digits': '0'\" type=\"number\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Expediente Nutricional<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-10\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Seleccione si usted o algun familiar directo padecen una de las siguientes enfermedades:<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-20\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-20-label\" class=\"forminator-label\">Diabetes<\/label><select id=\"forminator-form-615__field--select-20\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-20\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-21\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-21-label\" class=\"forminator-label\">Hipertensi\u00f3n<\/label><select id=\"forminator-form-615__field--select-21\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-21\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-22\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-22-label\" class=\"forminator-label\">Alteraci\u00f3n en colesterol<\/label><select id=\"forminator-form-615__field--select-22\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-22\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-23\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-23-label\" class=\"forminator-label\">Alteraci\u00f3n en triglic\u00e9rios<\/label><select id=\"forminator-form-615__field--select-23\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-23\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-24\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-24-label\" class=\"forminator-label\">Osteoporosis<\/label><select id=\"forminator-form-615__field--select-24\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-24\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-25\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-25-label\" class=\"forminator-label\">Gastritis<\/label><select id=\"forminator-form-615__field--select-25\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-25\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-26\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-26-label\" class=\"forminator-label\">Colitis<\/label><select id=\"forminator-form-615__field--select-26\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-26\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-27\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-27-label\" class=\"forminator-label\">Estre\u00f1imiento<\/label><select id=\"forminator-form-615__field--select-27\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-27\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-28\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-28-label\" class=\"forminator-label\">Enfermedad cel\u00edaca (alergia a gl\u00faten)<\/label><select id=\"forminator-form-615__field--select-28\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-28\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-29\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-29-label\" class=\"forminator-label\">H\u00edgado graso<\/label><select id=\"forminator-form-615__field--select-29\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-29\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-30\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-30-label\" class=\"forminator-label\">Ovario poliqu\u00edstico<\/label><select id=\"forminator-form-615__field--select-30\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-30\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-31\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-31-label\" class=\"forminator-label\">C\u00e1ncer<\/label><select id=\"forminator-form-615__field--select-31\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-31\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-32\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-32-label\" class=\"forminator-label\">Enfermedades del ri\u00f1\u00f3n<\/label><select id=\"forminator-form-615__field--select-32\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-32\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-33\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-33-label\" class=\"forminator-label\">Otras enfermedades importantes<\/label><select id=\"forminator-form-615__field--select-33\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-33\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-34\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-34-label\" class=\"forminator-label\">Alergias o intolerancias<\/label><select id=\"forminator-form-615__field--select-34\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-34\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-35\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-35-label\" class=\"forminator-label\">\u00bfConsume medicamentos, suplementos o hiervas naturales?<\/label><select id=\"forminator-form-615__field--select-35\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-35\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-8\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-8\" class=\"forminator-label\">\u00bfCu\u00e1les?<\/label><textarea name=\"textarea-8\" placeholder=\"\" id=\"forminator-field-textarea-8\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-9\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-9\" class=\"forminator-label\">Otros comentarios<\/label><textarea name=\"textarea-9\" placeholder=\"\" id=\"forminator-field-textarea-9\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-11\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">H\u00e1bitos<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-36\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-36-label\" class=\"forminator-label\">Actividad f\u00edsica<\/label><select id=\"forminator-form-615__field--select-36\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-36\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4\" class=\"forminator-label\">\u00bfCu\u00e1l?<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-4\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-4\" class=\"forminator-label\">Veces por semana<\/label><input name=\"number-4\" value=\"\" placeholder=\"\" id=\"forminator-field-number-4\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"'groupSeparator': '', 'radixPoint': '', 'digits': '0'\" type=\"number\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5\" class=\"forminator-label\">Duraci\u00f3n<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-37\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-37-label\" class=\"forminator-label\">\u00bfConsume bebidas alcoh\u00f3licas?<\/label><select id=\"forminator-form-615__field--select-37\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-37\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-10\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-10\" class=\"forminator-label\">Cantidad y frecuencia<\/label><textarea name=\"textarea-10\" placeholder=\"\" id=\"forminator-field-textarea-10\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-38\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-38-label\" class=\"forminator-label\">\u00bfRealiza las comidas a horarios regulares todos los d\u00edas?<\/label><select id=\"forminator-form-615__field--select-38\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-38\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-11\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-11\" class=\"forminator-label\">Alimentos que le disgusten:<\/label><textarea name=\"textarea-11\" placeholder=\"\" id=\"forminator-field-textarea-11\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-39\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-39-label\" class=\"forminator-label\">\u00bfSufre ansiedad?<\/label><select id=\"forminator-form-615__field--select-39\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-39\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-40\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-40-label\" class=\"forminator-label\">\u00bfEn qu\u00e9 momento del d\u00eda?<\/label><select id=\"forminator-form-615__field--select-40\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-40\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Ma\u00f1ana\"  data-calculation=\"0\">Ma\u00f1ana<\/option><option value=\"Tarde\"  data-calculation=\"0\">Tarde<\/option><option value=\"Noche\"  data-calculation=\"0\">Noche<\/option><option value=\"Todo-el-d\u00eda\"  data-calculation=\"0\">Todo el d\u00eda<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-41\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-41-label\" class=\"forminator-label\">\u00bfSufre atracones?<\/label><select id=\"forminator-form-615__field--select-41\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-41\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6\" class=\"forminator-label\">Frecuencia<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-12\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-12\" class=\"forminator-label\">\u00bfQu\u00e9 alimentos come?<\/label><textarea name=\"textarea-12\" placeholder=\"\" id=\"forminator-field-textarea-12\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-12\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Consumo usual: Indique lo que acostumbra a comer en cada tiempo de comida (indique porciones y horas). Sino hace algunos de los tiempos de comida, d\u00e9jelo en blanco.<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-13\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-13\" class=\"forminator-label\">Antes del desayuno<\/label><textarea name=\"textarea-13\" placeholder=\"\" id=\"forminator-field-textarea-13\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-14\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-14\" class=\"forminator-label\">Desayuno<\/label><textarea name=\"textarea-14\" placeholder=\"\" id=\"forminator-field-textarea-14\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-15\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-15\" class=\"forminator-label\">Merienda de la ma\u00f1ana<\/label><textarea name=\"textarea-15\" placeholder=\"\" id=\"forminator-field-textarea-15\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-16\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-16\" class=\"forminator-label\">Almuerzo<\/label><textarea name=\"textarea-16\" placeholder=\"\" id=\"forminator-field-textarea-16\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-17\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-17\" class=\"forminator-label\">Merienda de la tarde<\/label><textarea name=\"textarea-17\" placeholder=\"\" id=\"forminator-field-textarea-17\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-18\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-18\" class=\"forminator-label\">Cena<\/label><textarea name=\"textarea-18\" placeholder=\"\" id=\"forminator-field-textarea-18\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-19\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-19\" class=\"forminator-label\">Despu\u00e9s de la cena<\/label><textarea name=\"textarea-19\" placeholder=\"\" id=\"forminator-field-textarea-19\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Expediente de estado f\u00edsico<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-13\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Si tiene m\u00e1s de 69 a\u00f1os de edad, y no esta acostumbrado a estar activo, consulte a su m\u00e9dico.<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-42\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-42-label\" class=\"forminator-label\">\u00bfAlguna vez su m\u00e9dico le ha indicado que usted tiene un problema cardiovascular, y que solamente puede llevar a cabo ejercicios o actividad f\u00edsica si lo refiere un m\u00e9dico?<\/label><select id=\"forminator-form-615__field--select-42\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-42\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-43\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-43-label\" class=\"forminator-label\">\u00bfSufre de dolores frecuentes en el pecho cuando realiza alg\u00fan tipo de activivdad f\u00edsica?<\/label><select id=\"forminator-form-615__field--select-43\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-43\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-44\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-44-label\" class=\"forminator-label\">\u00bfEn el \u00faltimo mes, le ha dolido el pecho cuando no estaba haciendo actividad f\u00edsica?<\/label><select id=\"forminator-form-615__field--select-44\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-44\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-45\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-45-label\" class=\"forminator-label\">\u00bfCon frecuencia pierde el equilibrio debido a mareos, o alguna ves a perdido el conocimiento?<\/label><select id=\"forminator-form-615__field--select-45\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-45\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-46\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-46-label\" class=\"forminator-label\">\u00bfTiene problemas en los huesos o articulaciones (por ejemplo, en la espalda, rodillas o cadera) que pudiera agravarse al aumentar la activida f\u00edsica?<\/label><select id=\"forminator-form-615__field--select-46\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-46\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-47\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-47-label\" class=\"forminator-label\">\u00bfAl presente, le receta su m\u00e9dico medicamentos ( por ejemplo pastillas de agua-diuretico) para la presi\u00f3n arterial, o problemas con el coraz\u00f3n?<\/label><select id=\"forminator-form-615__field--select-47\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-47\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-48\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-48-label\" class=\"forminator-label\">\u00bfExiste alguna otra raz\u00f3n por la cual no deberia participar en un programa de actividad f\u00edsica?<\/label><select id=\"forminator-form-615__field--select-48\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-48\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-49\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-615__field--select-49-label\" class=\"forminator-label\">\u00bfUsted esta en capacidad de caminar 200, 500, 800 metros constantemente?<\/label><select id=\"forminator-form-615__field--select-49\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-49\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Si\"  data-calculation=\"0\">Si<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-14\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">\u201cYo he le\u00eddo, contestado y completado el cuestionario. Todas las preguntas fueron respondidas a mi entera satisfacci\u00f3n.\u201d<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2\" class=\"forminator-label\">Nombre<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-1\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-1\" class=\"forminator-label\">Firma<\/label><div class=\"forminator-file-upload \" data-element=\"upload-1\"><input type=\"file\" name=\"upload-1\" id=\"forminator-field-upload-1\" class=\"forminator-input-file\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.ico,.heic,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.flv,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.css,.htm,.html,.vtt,.dfxp,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.js,.pdf,.class,.tar,.zip,.gz,.gzip,.rar,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mdb,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onetmp,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages\"><button class=\"forminator-upload--remove\" style=\"display: none;\">Remove<\/button><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker-6a2d97301907d\" class=\"forminator-label\">Fecha<\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-2-picker-6a2d97301907d\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"\" id=\"forminator-field-date-2-picker-6a2d97301907d\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-15\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">NOTA: Este cuestionario es v\u00e1lido hasta por un m\u00e1ximo de 12 meses, a partir de la fecha en que se completa. El mismo se invalida si su estado de salud requiere contestar SI en alguna de las preguntas. La empresa tour operadora OSA VERDE Y MAR y sus profesionales de la salud, no asumen ninguna responsabilidad legal para con las personas que participan en este programa de BIENESTAR Y SALUD \u2013 WELLNESS en caso de duda despu\u00e9s de completar este cuestionario, consulte primero a su m\u00e9dico.<\/label><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Enviar<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"d371b7c671\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F165\" \/><input type=\"hidden\" name=\"form_id\" value=\"615\"><input type=\"hidden\" name=\"page_id\" value=\"165\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"http:\/\/osaverdeymar.com\/?rest_route=%2Fwp%2Fv2%2Fpages%2F165\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:10%\"><\/div>\n<\/div>\n\n\n\n<div style=\"height:100px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><strong>Health Record<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\">Please complete this form and we will give you an answer shortly.<\/p>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-8f761849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:10%\"><\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:70%\">\n<div class=\"forminator-guttenberg\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-621   forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-621\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-621\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-621   forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"621\"\n\t\t\t\t\n\t\t\t\tdata-design=\"none\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\tenctype=\"multipart\/form-data\"\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t><div class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Personal Information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1\" class=\"forminator-label\">Country<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-2\" class=\"forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2\" class=\"forminator-label\">State<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1\" class=\"forminator-label\">Full Name<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"select-1\" class=\"forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-1-label\" class=\"forminator-label\">Gender<\/label><select id=\"forminator-form-621__field--select-1\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-1\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Male\"  data-calculation=\"0\">Male<\/option><option value=\"Feminine\"  data-calculation=\"0\">Feminine<\/option><option value=\"Rather-not-tell\"  data-calculation=\"0\">Rather not tell<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-1\" class=\"forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-1\" class=\"forminator-label\">Age<\/label><input name=\"number-1\" value=\"\" placeholder=\"\" id=\"forminator-field-number-1\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"'groupSeparator': '', 'radixPoint': '', 'digits': '0'\" type=\"number\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker-6a2d97304f214\" class=\"forminator-label\">Date of Birth<\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-1-picker-6a2d97304f214\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-picker-6a2d97304f214\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"number-2\" class=\"forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-2\" class=\"forminator-label\">ID number<\/label><input name=\"number-2\" value=\"\" placeholder=\"\" id=\"forminator-field-number-2\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"'groupSeparator': '', 'radixPoint': '', 'digits': '0'\" type=\"number\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3\" class=\"forminator-label\">Occupation<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1\" class=\"forminator-label\">Phone Number<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1\" class=\"forminator-label\">E-mail address<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Physical Condition<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Are you independent to perform physical activity such as?<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-2\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-2-label\" class=\"forminator-label\">Walking<\/label><select id=\"forminator-form-621__field--select-2\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-2\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-3\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-3-label\" class=\"forminator-label\">Washing your hands<\/label><select id=\"forminator-form-621__field--select-3\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-3\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-4\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-4-label\" class=\"forminator-label\">Going to the bathroom<\/label><select id=\"forminator-form-621__field--select-4\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-4\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-2\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Instrumentals<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-5\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-5-label\" class=\"forminator-label\">Are you able to engage in cognitive processes such as memory usage, paying attention, perception, creativity and simple calculations?<\/label><select id=\"forminator-form-621__field--select-5\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-5\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-3\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Medical devices<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-6\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-6-label\" class=\"forminator-label\">Do you need a permanent Foley catheter?<\/label><select id=\"forminator-form-621__field--select-6\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-6\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-7\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-7-label\" class=\"forminator-label\">Do you require oxygen supply?<\/label><select id=\"forminator-form-621__field--select-7\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-7\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-8\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-8-label\" class=\"forminator-label\">Do you use a pacemaker?<\/label><select id=\"forminator-form-621__field--select-8\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-8\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-14\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-14-label\" class=\"forminator-label\">Other<\/label><select id=\"forminator-form-621__field--select-14\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-14\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1\" class=\"forminator-label\">Which one\/s?<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-4\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Chronic Conditions<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-10\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-10-label\" class=\"forminator-label\">High Blood Pressure<\/label><select id=\"forminator-form-621__field--select-10\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-10\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-11\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-11-label\" class=\"forminator-label\">Diabetes<\/label><select id=\"forminator-form-621__field--select-11\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-11\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-12\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-12-label\" class=\"forminator-label\">COPD<\/label><select id=\"forminator-form-621__field--select-12\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-12\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-13\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-13-label\" class=\"forminator-label\">Other?<\/label><select id=\"forminator-form-621__field--select-13\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-13\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2\" class=\"forminator-label\">Which one\/s?<\/label><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-5\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Chronic treatments<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-3\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3\" class=\"forminator-label\">Medicine names, schedule, and dosage<\/label><textarea name=\"textarea-3\" placeholder=\"\" id=\"forminator-field-textarea-3\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-4\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4\" class=\"forminator-label\">Insuline<\/label><textarea name=\"textarea-4\" placeholder=\"\" id=\"forminator-field-textarea-4\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-6\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Medicinal Allergies<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-5\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-5\" class=\"forminator-label\">Explain<\/label><textarea name=\"textarea-5\" placeholder=\"\" id=\"forminator-field-textarea-5\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-7\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Vaccination schedule: Infant immunization schedule: (we ask this information because the anti-vaccine movement is frequent in foreigners. We require this information for prevention)<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-15\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-15-label\" class=\"forminator-label\">Varicella<\/label><select id=\"forminator-form-621__field--select-15\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-15\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-16\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-16-label\" class=\"forminator-label\">Measles<\/label><select id=\"forminator-form-621__field--select-16\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-16\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-17\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-17-label\" class=\"forminator-label\">Rubella<\/label><select id=\"forminator-form-621__field--select-17\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-17\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-18\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-18-label\" class=\"forminator-label\">Mumps<\/label><select id=\"forminator-form-621__field--select-18\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-18\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-8\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Based on region of provenance:<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-19\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-19-label\" class=\"forminator-label\">If you come from South America, yellow fever<\/label><select id=\"forminator-form-621__field--select-19\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-19\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-9\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">COVID<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-6\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-6\" class=\"forminator-label\">Pharmaceutical company<\/label><textarea name=\"textarea-6\" placeholder=\"\" id=\"forminator-field-textarea-6\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-7\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-7\" class=\"forminator-label\">Date of application<\/label><textarea name=\"textarea-7\" placeholder=\"\" id=\"forminator-field-textarea-7\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-3\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-3\" class=\"forminator-label\">Number of applications<\/label><input name=\"number-3\" value=\"\" placeholder=\"\" id=\"forminator-field-number-3\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"'groupSeparator': '', 'radixPoint': '', 'digits': '0'\" type=\"number\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Surgical and trauma history<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-10\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Select if you or any direct relative have any of the following conditions:<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-20\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-20-label\" class=\"forminator-label\">Diabetes<\/label><select id=\"forminator-form-621__field--select-20\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-20\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-21\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-21-label\" class=\"forminator-label\">High Blood Pressure<\/label><select id=\"forminator-form-621__field--select-21\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-21\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-22\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-22-label\" class=\"forminator-label\">Altered Cholesterol<\/label><select id=\"forminator-form-621__field--select-22\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-22\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-23\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-23-label\" class=\"forminator-label\">Altered Triglycerides<\/label><select id=\"forminator-form-621__field--select-23\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-23\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-24\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-24-label\" class=\"forminator-label\">Osteoporosis<\/label><select id=\"forminator-form-621__field--select-24\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-24\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-25\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-25-label\" class=\"forminator-label\">Gastritis<\/label><select id=\"forminator-form-621__field--select-25\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-25\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-26\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-26-label\" class=\"forminator-label\">Colitis<\/label><select id=\"forminator-form-621__field--select-26\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-26\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-27\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-27-label\" class=\"forminator-label\">Constipation<\/label><select id=\"forminator-form-621__field--select-27\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-27\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-28\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-28-label\" class=\"forminator-label\">Celiac disease (gluten allergy)<\/label><select id=\"forminator-form-621__field--select-28\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-28\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-29\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-29-label\" class=\"forminator-label\">Fatty liver<\/label><select id=\"forminator-form-621__field--select-29\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-29\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-30\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-30-label\" class=\"forminator-label\">Polycystic ovary<\/label><select id=\"forminator-form-621__field--select-30\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-30\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-31\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-31-label\" class=\"forminator-label\">Cancer<\/label><select id=\"forminator-form-621__field--select-31\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-31\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-32\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-32-label\" class=\"forminator-label\">Kidney diseases<\/label><select id=\"forminator-form-621__field--select-32\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-32\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-33\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-33-label\" class=\"forminator-label\">Other major diseases<\/label><select id=\"forminator-form-621__field--select-33\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-33\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-34\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-34-label\" class=\"forminator-label\">Allergies or intolerances<\/label><select id=\"forminator-form-621__field--select-34\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-34\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-35\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-35-label\" class=\"forminator-label\">Do you take medications, supplements or natural herbs?<\/label><select id=\"forminator-form-621__field--select-35\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-35\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-8\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-8\" class=\"forminator-label\">Which one\/s?<\/label><textarea name=\"textarea-8\" placeholder=\"\" id=\"forminator-field-textarea-8\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-9\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-9\" class=\"forminator-label\">Other comments<\/label><textarea name=\"textarea-9\" placeholder=\"\" id=\"forminator-field-textarea-9\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-11\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Habits<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-36\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-36-label\" class=\"forminator-label\">Physical activity<\/label><select id=\"forminator-form-621__field--select-36\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-36\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4\" class=\"forminator-label\">Which one\/s?<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-4\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-4\" class=\"forminator-label\">Frequency<\/label><input name=\"number-4\" value=\"\" placeholder=\"\" id=\"forminator-field-number-4\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"'groupSeparator': '', 'radixPoint': '', 'digits': '0'\" type=\"number\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5\" class=\"forminator-label\">Activity duration<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-37\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-37-label\" class=\"forminator-label\">Do you consume alcoholic beverages?<\/label><select id=\"forminator-form-621__field--select-37\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-37\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-10\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-10\" class=\"forminator-label\">Quantity and frequency<\/label><textarea name=\"textarea-10\" placeholder=\"\" id=\"forminator-field-textarea-10\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-38\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-38-label\" class=\"forminator-label\">Do you eat meals at regular times every day?<\/label><select id=\"forminator-form-621__field--select-38\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-38\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-11\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-11\" class=\"forminator-label\">Disliked foods:<\/label><textarea name=\"textarea-11\" placeholder=\"\" id=\"forminator-field-textarea-11\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-39\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-39-label\" class=\"forminator-label\">Do you suffer from anxiety?<\/label><select id=\"forminator-form-621__field--select-39\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-39\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-40\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-40-label\" class=\"forminator-label\">What time of day?<\/label><select id=\"forminator-form-621__field--select-40\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-40\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Morning\"  data-calculation=\"0\">Morning<\/option><option value=\"Afternoon\"  data-calculation=\"0\">Afternoon<\/option><option value=\"Night\"  data-calculation=\"0\">Night<\/option><option value=\"All-day\"  data-calculation=\"0\">All day<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-41\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-41-label\" class=\"forminator-label\">Do you suffer from binge eating?<\/label><select id=\"forminator-form-621__field--select-41\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-41\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6\" class=\"forminator-label\">Frequency<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-12\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-12\" class=\"forminator-label\">What food do you eat?<\/label><textarea name=\"textarea-12\" placeholder=\"\" id=\"forminator-field-textarea-12\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-12\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">Usual consumption: Indicate what you usually eat at each meal time (indicate portions and hours). If you don&#039;t do some of the meal times, leave it blank.<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-13\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-13\" class=\"forminator-label\">Before breakfast<\/label><textarea name=\"textarea-13\" placeholder=\"\" id=\"forminator-field-textarea-13\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-14\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-14\" class=\"forminator-label\">Breakfast<\/label><textarea name=\"textarea-14\" placeholder=\"\" id=\"forminator-field-textarea-14\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-15\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-15\" class=\"forminator-label\">Morning snack<\/label><textarea name=\"textarea-15\" placeholder=\"\" id=\"forminator-field-textarea-15\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-16\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-16\" class=\"forminator-label\">Lunch<\/label><textarea name=\"textarea-16\" placeholder=\"\" id=\"forminator-field-textarea-16\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-17\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-17\" class=\"forminator-label\">Afternoon snack<\/label><textarea name=\"textarea-17\" placeholder=\"\" id=\"forminator-field-textarea-17\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-18\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-18\" class=\"forminator-label\">Dinner<\/label><textarea name=\"textarea-18\" placeholder=\"\" id=\"forminator-field-textarea-18\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-19\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-19\" class=\"forminator-label\">After dinner<\/label><textarea name=\"textarea-19\" placeholder=\"\" id=\"forminator-field-textarea-19\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Physical status record<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-13\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">If you are over 69 years of age, and you are not used to being active, consult your doctor.<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-42\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-42-label\" class=\"forminator-label\">Has your doctor ever told you that you have a cardiovascular problem, and that you can only carry out exercises or physical activity if you are referred by a doctor?<\/label><select id=\"forminator-form-621__field--select-42\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-42\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-43\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-43-label\" class=\"forminator-label\">Do you suffer from frequent chest pains when you do any type of physical activity?<\/label><select id=\"forminator-form-621__field--select-43\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-43\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-44\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-44-label\" class=\"forminator-label\">In the last month, has your chest hurt when you were not physically active?<\/label><select id=\"forminator-form-621__field--select-44\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-44\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-45\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-45-label\" class=\"forminator-label\">Do you frequently lose your balance due to dizziness, or have you ever lost consciousness?<\/label><select id=\"forminator-form-621__field--select-45\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-45\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-46\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-46-label\" class=\"forminator-label\">Do you have bone or joint problems (for example, in your back, knees, or hips) that could be aggravated by increased physical activity?<\/label><select id=\"forminator-form-621__field--select-46\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-46\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-47\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-47-label\" class=\"forminator-label\">Does your doctor currently prescribe medication (for example water-diuretic pills) for blood pressure or heart problems?<\/label><select id=\"forminator-form-621__field--select-47\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-47\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-48\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-48-label\" class=\"forminator-label\">Are there any other reasons why I should not participate in a physical activity program?<\/label><select id=\"forminator-form-621__field--select-48\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-48\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-49\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-621__field--select-49-label\" class=\"forminator-label\">Are you capable of walking 200, 500, 800 meters constantly?<\/label><select id=\"forminator-form-621__field--select-49\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-49\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-14\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">\u201cI have read, answered and completed the questionnaire. All questions were answered to my complete satisfaction.\u201d<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2\" class=\"forminator-label\">Name<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-1\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-1\" class=\"forminator-label\">Signature<\/label><div class=\"forminator-file-upload \" data-element=\"upload-1\"><input type=\"file\" name=\"upload-1\" id=\"forminator-field-upload-1\" class=\"forminator-input-file\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.ico,.heic,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.flv,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.css,.htm,.html,.vtt,.dfxp,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.js,.pdf,.class,.tar,.zip,.gz,.gzip,.rar,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mdb,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onetmp,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages\"><button class=\"forminator-upload--remove\" style=\"display: none;\">Remove<\/button><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker-6a2d97305051b\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-2-picker-6a2d97305051b\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"\" id=\"forminator-field-date-2-picker-6a2d97305051b\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-15\" class=\"forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\"><label class=\"forminator-label\">NOTE: This questionnaire is valid for a maximum of 12 months from the date it is completed. It is invalidated if your health condition requires you to answer YES to any of the questions. The tour operator company OSA VERDE Y MAR and its health professionals do not assume any legal responsibility towards the people who participate in this BIENESTAR Y SALUD \u2013 WELLNESS program. In case of doubt after completing this questionnaire, consult your doctor first. .<\/label><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Send<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"d371b7c671\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F165\" \/><input type=\"hidden\" name=\"form_id\" value=\"621\"><input type=\"hidden\" name=\"page_id\" value=\"165\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"http:\/\/osaverdeymar.com\/?rest_route=%2Fwp%2Fv2%2Fpages%2F165\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:10%\"><\/div>\n<\/div>\n\n\n\n<div style=\"height:100px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n","protected":false},"excerpt":{"rendered":"<p>Expediente de Salud Por favor complete este formulario y en breve le daremos una respuesta. Health Record Please complete this form and we will give you an answer shortly.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"template-gutentor-full-width.php","meta":{"footnotes":""},"class_list":["post-165","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"http:\/\/osaverdeymar.com\/index.php?rest_route=\/wp\/v2\/pages\/165","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/osaverdeymar.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/osaverdeymar.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/osaverdeymar.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/osaverdeymar.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=165"}],"version-history":[{"count":29,"href":"http:\/\/osaverdeymar.com\/index.php?rest_route=\/wp\/v2\/pages\/165\/revisions"}],"predecessor-version":[{"id":624,"href":"http:\/\/osaverdeymar.com\/index.php?rest_route=\/wp\/v2\/pages\/165\/revisions\/624"}],"wp:attachment":[{"href":"http:\/\/osaverdeymar.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=165"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}