{"id":888,"date":"2023-02-21T11:16:56","date_gmt":"2023-02-21T16:16:56","guid":{"rendered":"https:\/\/forms.blossomhc.net\/?page_id=888"},"modified":"2023-02-21T11:16:56","modified_gmt":"2023-02-21T16:16:56","slug":"annual-health-assessment-spanish","status":"publish","type":"page","link":"https:\/\/forms.blossomhc.net\/annual-health-assessment-spanish\/","title":{"rendered":"Annual Health Assessment Spanish"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Annual Health Assessment: Spanish<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/wp-json\/wp\/v2\/pages\/888' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_50\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_50\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_3_4\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_4\" ><label class='gfield_label gform-field-label' for='input_3_4'>Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_3_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_36\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_36\" ><label class='gfield_label gform-field-label' for='input_3_36'>\u00daltimos 4 de SSN#<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_3_36' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_7\" class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_7\" ><label class='gfield_label gform-field-label' for='input_3_7'>Tel\u00e9fono<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_3_7' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_51\" class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_51\" ><label class='gfield_label gform-field-label' for='input_3_51'>Correo Electronico<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_51' id='input_3_51' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_3_5\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_5\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >DIRECCI\u00d3N<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_3_5_1' value=''   placeholder='Street Address' aria-required='true'    \/>\n                                        <label for='input_3_5_1' id='input_3_5_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_5_2_container' >\n                                        <input type='text' name='input_5.2' id='input_3_5_2' value=''   placeholder='Address Line 2'  aria-required='false'   \/>\n                                        <label for='input_3_5_2' id='input_3_5_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_3_5_3' value=''   placeholder='ciudad' aria-required='true'    \/>\n                                    <label for='input_3_5_3' id='input_3_5_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_5_4_container' >\n                                        <input type='text' name='input_5.4' id='input_3_5_4' value=''     placeholder='estado' aria-required='true'    \/>\n                                        <label for='input_3_5_4' id='input_3_5_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_3_5_5' value=''   placeholder='Zip' aria-required='true'    \/>\n                                    <label for='input_3_5_5' id='input_3_5_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_5.6' id='input_3_5_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_13\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_13\" >\u00bfHa tenido o tiene alguna de las siguientes afecciones\/s\u00edntomas?<\/div><fieldset id=\"field_3_35\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_35\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Alergia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_35'><div class='gchoice gchoice_3_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='S\u00ed'  id='choice_3_35_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_35_1' id='label_3_35_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_35_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.2' type='checkbox'  value='No'  id='choice_3_35_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_35_2' id='label_3_35_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_40\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_40\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Artristi<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_40'><div class='gchoice gchoice_3_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='S\u00ed'  id='choice_3_40_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_40_1' id='label_3_40_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_40_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.2' type='checkbox'  value='No'  id='choice_3_40_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_40_2' id='label_3_40_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_47\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_47\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Convulsiones<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_47'><div class='gchoice gchoice_3_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='S\u00ed'  id='choice_3_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_1' id='label_3_47_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='No'  id='choice_3_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_2' id='label_3_47_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_42\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_42\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Diabetes<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_42'><div class='gchoice gchoice_3_42_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.1' type='checkbox'  value='S\u00ed'  id='choice_3_42_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_42_1' id='label_3_42_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_42_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.2' type='checkbox'  value='No'  id='choice_3_42_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_42_2' id='label_3_42_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_43\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_43\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Problemas Card\u00edacos<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_43'><div class='gchoice gchoice_3_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='S\u00ed'  id='choice_3_43_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_43_1' id='label_3_43_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_43_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.2' type='checkbox'  value='No'  id='choice_3_43_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_43_2' id='label_3_43_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_44\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Exposici\u00f3n a la Hepatitis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_44'><div class='gchoice gchoice_3_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='S\u00ed'  id='choice_3_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_1' id='label_3_44_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='No'  id='choice_3_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_44_2' id='label_3_44_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_45\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_45\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Presi\u00f3n Arterial Alta<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_45'><div class='gchoice gchoice_3_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='S\u00ed'  id='choice_3_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_1' id='label_3_45_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='No'  id='choice_3_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_45_2' id='label_3_45_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_46\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_46\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cirug\u00eda en el \u00faltimo a\u00f1o<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_46'><div class='gchoice gchoice_3_46_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.1' type='checkbox'  value='S\u00ed'  id='choice_3_46_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_46_1' id='label_3_46_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_46_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.2' type='checkbox'  value='No'  id='choice_3_46_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_46_2' id='label_3_46_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_41\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_41\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Problemas de Espalda<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_41'><div class='gchoice gchoice_3_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='S\u00ed'  id='choice_3_41_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_41_1' id='label_3_41_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_41_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.2' type='checkbox'  value='No'  id='choice_3_41_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_41_2' id='label_3_41_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_22\" ><legend class='gfield_label gform-field-label' >\u00bfHa recibido ALGUNA vacuna, como vacunas contra la gripe o el t\u00e9tanos, en el \u00faltimo a\u00f1o?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_22'>\n\t\t\t<div class='gchoice gchoice_3_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes'  id='choice_3_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_22_0' id='label_3_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_3_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_22_1' id='label_3_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_23\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_23\" ><label class='gfield_label gform-field-label' for='input_3_23'>En caso afirmativo, fecha y tipo de inmunizaci\u00f3n<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_3_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_25\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_25\" >Nombre del m\u00e9dico con el que desea que nos pongamos en contacto en caso de cualquier emergencia o enfermedad: \n<\/div><div id=\"field_3_24\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_24\" ><label class='gfield_label gform-field-label' for='input_3_24'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_3_24' type='text' value='' class='large'    placeholder='Nombre del medico' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_26\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_26\" ><label class='gfield_label gform-field-label' for='input_3_26'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_3_26' type='text' value='' class='large'    placeholder='N\u00famero de tel\u00e9fono del m\u00e9dico' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_3_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_27\" ><legend class='gfield_label gform-field-label' >\u00bfTiene alg\u00fan impedimento para la salud que sea de riesgo potencial para el paciente, o que pueda interferir con el desempe\u00f1o de sus funciones, incluida la habituaci\u00f3n o adicci\u00f3n a depresores, estimulantes, narc\u00f3ticos, alcohol u otras drogas que puedan alterar su comportamiento?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_27'>\n\t\t\t<div class='gchoice gchoice_3_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='S\u00ed'  id='choice_3_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_27_0' id='label_3_27_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='No'  id='choice_3_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_27_1' id='label_3_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_28\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_28\" ><label class='gfield_label gform-field-label' for='input_3_28'>En caso afirmativo, explique<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_3_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_29\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_29\" ><label class='gfield_label gform-field-label' for='input_3_29'>\u00bfCu\u00e1l es su peso actual?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_29' id='input_3_29' type='number' step='any'   value='' class='large'    placeholder='Introduzca un valor num\u00e9rico en libras.' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_3_31\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_31\" ><label class='gfield_label gform-field-label' for='input_3_31'>\u00bfAltura actual?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_31' id='input_3_31' type='number' step='any'   value='' class='large'    placeholder='Introduzca un valor num\u00e9rico en pulgadas.' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_3_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_32\" ><legend class='gfield_label gform-field-label' >\u00bfEst\u00e1 tomando actualmente medicamentos recetados por un m\u00e9dico?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_32'>\n\t\t\t<div class='gchoice gchoice_3_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='S\u00ed'  id='choice_3_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_32_0' id='label_3_32_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='No'  id='choice_3_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_32_1' id='label_3_32_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_33\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_33\" ><label class='gfield_label gform-field-label' for='input_3_33'>En caso afirmativo, qu\u00e9 medicamento y por qu\u00e9 raz\u00f3n?<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_3_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_3_34\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_34\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Certification<\/legend><div class='ginput_container ginput_container_consent'><input name='input_34.1' id='input_3_34_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_34_1' >Certifico que la informaci\u00f3n que he proporcionado sobre esta evaluaci\u00f3n de salud es fiel a mi leal saber y entender. Entiendo que esta evaluaci\u00f3n no es para fines de diagn\u00f3stico o tratamiento, ni reemplaza el examen m\u00e9dico de mi m\u00e9dico.<\/label><input type='hidden' name='input_34.2' value='Certifico que la informaci\u00f3n que he proporcionado sobre esta evaluaci\u00f3n de salud es fiel a mi leal saber y entender. Entiendo que esta evaluaci\u00f3n no es para fines de diagn\u00f3stico o tratamiento, ni reemplaza el examen m\u00e9dico de mi m\u00e9dico.' class='gform_hidden' \/><input type='hidden' name='input_34.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_3_48\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_48\" ><label class='gfield_label gform-field-label' for='input_3_48'>Firma<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_3_48' type='text' value='' class='large'    placeholder='Por favor escriba su nombre completo.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_38\" class=\"gfield gfield--type-date 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*\/\n<\/script>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":8,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.0 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Annual Health Assessment Spanish - Blossom Home Care<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/forms.blossomhc.net\/annual-health-assessment-spanish\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Annual Health Assessment Spanish - Blossom Home Care\" \/>\n<meta property=\"og:url\" content=\"https:\/\/forms.blossomhc.net\/annual-health-assessment-spanish\/\" \/>\n<meta property=\"og:site_name\" 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