{"id":180,"date":"2023-09-20T07:08:18","date_gmt":"2023-09-20T07:08:18","guid":{"rendered":"https:\/\/mujerimpacta.com\/?page_id=180"},"modified":"2024-01-13T19:04:26","modified_gmt":"2024-01-13T19:04:26","slug":"medical-form","status":"publish","type":"page","link":"https:\/\/drjaimeponcedeleon.com.mx\/es\/medical-form\/","title":{"rendered":"Formulario M\u00e9dico"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"180\" class=\"elementor elementor-180\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-51462a7b elementor-section-height-min-height elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"51462a7b\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;gradient&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-extended\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-26f33e5\" data-id=\"26f33e5\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-48e8309e elementor-widget elementor-widget-heading\" data-id=\"48e8309e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Medical Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-19ae13a3 elementor-widget elementor-widget-image\" data-id=\"19ae13a3\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/drjaimeponcedeleon.com.mx\/wp-content\/uploads\/elementor\/thumbs\/graphic-6-qnhljf89q7xssjhrhkl9btl16hfgdo6v9homzpsrnk.png\" title=\"graphic-6.png\" alt=\"graphic-6.png\" loading=\"lazy\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-47e68dbd\" data-id=\"47e68dbd\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-58665cda elementor-invisible elementor-widget elementor-widget-image\" data-id=\"58665cda\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;slideInRight&quot;,&quot;_animation_delay&quot;:200}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/drjaimeponcedeleon.com.mx\/wp-content\/uploads\/elementor\/thumbs\/DSC01100-scaled-1-qnhljf8cfkuqm652x5zavfeebk83byivs80p8xbb06.jpg\" title=\"DSC01100-scaled\" alt=\"DSC01100-scaled\" loading=\"lazy\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-18bca637 elementor-widget__width-initial elementor-absolute elementor-widget elementor-widget-image\" data-id=\"18bca637\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_position&quot;:&quot;absolute&quot;}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/mujerimpacta.com\/wp-content\/uploads\/2023\/09\/graphic-7.png\" title=\"\" alt=\"\" loading=\"lazy\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-1397f9c8 elementor-widget__width-initial elementor-absolute elementor-widget elementor-widget-spacer\" data-id=\"1397f9c8\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_position&quot;:&quot;absolute&quot;}\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t<div class=\"elementor-element elementor-element-4494f1e2 e-flex e-con-boxed e-con e-parent\" data-id=\"4494f1e2\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-66ac2a57 elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"66ac2a57\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"Medical Form\" aria-label=\"Medical Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"180\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"66ac2a57\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Medical Form\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"180\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_b72c725 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"General Data\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFull Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Name\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-email elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Email\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_501e55c elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_501e55c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAge\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_501e55c]\" id=\"form-field-field_501e55c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Age\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_fc4ef55 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fc4ef55\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMarital Status\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_fc4ef55]\" id=\"form-field-field_fc4ef55\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Marital Status\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c7f6e3f elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c7f6e3f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCity \u200b\u200bof birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c7f6e3f]\" id=\"form-field-field_c7f6e3f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"City \u200b\u200bof birth\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8474c53 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8474c53\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCity of residence\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8474c53]\" id=\"form-field-field_8474c53\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"City of residence\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_bd29661 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bd29661\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOcupation\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_bd29661]\" id=\"form-field-field_bd29661\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Ocupation\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_3731b21 elementor-col-75\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3731b21\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFamily illness\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Diabetes\" id=\"form-field-field_3731b21-0\" name=\"form_fields[field_3731b21][]\"> <label for=\"form-field-field_3731b21-0\">Diabetes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hypertention\" id=\"form-field-field_3731b21-1\" name=\"form_fields[field_3731b21][]\"> <label for=\"form-field-field_3731b21-1\">Hypertention<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cancer\" id=\"form-field-field_3731b21-2\" name=\"form_fields[field_3731b21][]\"> <label for=\"form-field-field_3731b21-2\">Cancer<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Kidney Desease\" id=\"form-field-field_3731b21-3\" name=\"form_fields[field_3731b21][]\"> <label for=\"form-field-field_3731b21-3\">Kidney Desease<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Mental illness\" id=\"form-field-field_3731b21-4\" name=\"form_fields[field_3731b21][]\"> <label for=\"form-field-field_3731b21-4\">Mental illness<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_77a1f66 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Personal History\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f2b7e10 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f2b7e10\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWeight\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f2b7e10]\" id=\"form-field-field_f2b7e10\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Weight\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c48e31d elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c48e31d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHeight\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c48e31d]\" id=\"form-field-field_c48e31d\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Height\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_4b07a79 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4b07a79\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you smoke or have you smoked?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_4b07a79-0\" name=\"form_fields[field_4b07a79]\"> <label for=\"form-field-field_4b07a79-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_4b07a79-1\" name=\"form_fields[field_4b07a79]\"> <label for=\"form-field-field_4b07a79-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_d22f824 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d22f824\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you had previous surgeries?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_d22f824-0\" name=\"form_fields[field_d22f824]\"> <label for=\"form-field-field_d22f824-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_d22f824-1\" name=\"form_fields[field_d22f824]\"> <label for=\"form-field-field_d22f824-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_9bb3984 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9bb3984\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf you answered yes in previous surgery\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9bb3984]\" id=\"form-field-field_9bb3984\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"What surgery?\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_e22619b elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e22619b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you used illegal drugs?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_e22619b-0\" name=\"form_fields[field_e22619b]\"> <label for=\"form-field-field_e22619b-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_e22619b-1\" name=\"form_fields[field_e22619b]\"> <label for=\"form-field-field_e22619b-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5e715ac elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5e715ac\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf you answered yes in illegal drugs\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5e715ac]\" id=\"form-field-field_5e715ac\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"What drugs?\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_5944c02 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Women Only\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_69be790 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_69be790\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre you pregnant?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_69be790-0\" name=\"form_fields[field_69be790]\"> <label for=\"form-field-field_69be790-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_69be790-1\" name=\"form_fields[field_69be790]\"> <label for=\"form-field-field_69be790-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_46d71f7 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_46d71f7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNumber of living children?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_46d71f7]\" id=\"form-field-field_46d71f7\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_258f1f7 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_258f1f7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMethod of birth control?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_258f1f7]\" id=\"form-field-field_258f1f7\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_ea9f779 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ea9f779\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNumber of caesarean sections\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_ea9f779]\" id=\"form-field-field_ea9f779\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_c784f45 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Diseases\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_ee9ef0c elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cancer\" id=\"form-field-field_ee9ef0c-0\" name=\"form_fields[field_ee9ef0c][]\"> <label for=\"form-field-field_ee9ef0c-0\">Cancer<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Heart Diseases\" id=\"form-field-field_ee9ef0c-1\" name=\"form_fields[field_ee9ef0c][]\"> <label for=\"form-field-field_ee9ef0c-1\">Heart Diseases<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"High blood pressure\" id=\"form-field-field_ee9ef0c-2\" name=\"form_fields[field_ee9ef0c][]\"> <label for=\"form-field-field_ee9ef0c-2\">High blood pressure<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Kidney Diseases\" id=\"form-field-field_ee9ef0c-3\" name=\"form_fields[field_ee9ef0c][]\"> <label for=\"form-field-field_ee9ef0c-3\">Kidney Diseases<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Mental Illness\" id=\"form-field-field_ee9ef0c-4\" name=\"form_fields[field_ee9ef0c][]\"> <label for=\"form-field-field_ee9ef0c-4\">Mental Illness<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Tuberculosis\" id=\"form-field-field_ee9ef0c-5\" name=\"form_fields[field_ee9ef0c][]\"> <label for=\"form-field-field_ee9ef0c-5\">Tuberculosis<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Convulsions\" id=\"form-field-field_ee9ef0c-6\" name=\"form_fields[field_ee9ef0c][]\"> <label for=\"form-field-field_ee9ef0c-6\">Convulsions<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Asthma or Bronchitis\" id=\"form-field-field_ee9ef0c-7\" name=\"form_fields[field_ee9ef0c][]\"> <label for=\"form-field-field_ee9ef0c-7\">Asthma or Bronchitis<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Castric Ulcers\" id=\"form-field-field_ee9ef0c-8\" name=\"form_fields[field_ee9ef0c][]\"> <label for=\"form-field-field_ee9ef0c-8\">Castric Ulcers<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hepatitis\" id=\"form-field-field_ee9ef0c-9\" name=\"form_fields[field_ee9ef0c][]\"> <label for=\"form-field-field_ee9ef0c-9\">Hepatitis<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Blood diseases\" id=\"form-field-field_ee9ef0c-10\" name=\"form_fields[field_ee9ef0c][]\"> <label for=\"form-field-field_ee9ef0c-10\">Blood diseases<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Palpitations\" id=\"form-field-field_ee9ef0c-11\" name=\"form_fields[field_ee9ef0c][]\"> <label for=\"form-field-field_ee9ef0c-11\">Palpitations<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Glaucoma\" id=\"form-field-field_ee9ef0c-12\" name=\"form_fields[field_ee9ef0c][]\"> <label for=\"form-field-field_ee9ef0c-12\">Glaucoma<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Parasites\" id=\"form-field-field_ee9ef0c-13\" name=\"form_fields[field_ee9ef0c][]\"> <label for=\"form-field-field_ee9ef0c-13\">Parasites<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Anemia\" id=\"form-field-field_ee9ef0c-14\" name=\"form_fields[field_ee9ef0c][]\"> <label for=\"form-field-field_ee9ef0c-14\">Anemia<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Arthritis\" id=\"form-field-field_ee9ef0c-15\" name=\"form_fields[field_ee9ef0c][]\"> <label for=\"form-field-field_ee9ef0c-15\">Arthritis<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_d3ae93f elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d3ae93f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you require?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Stick\" id=\"form-field-field_d3ae93f-0\" name=\"form_fields[field_d3ae93f][]\"> <label for=\"form-field-field_d3ae93f-0\">Stick<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Crutches\" id=\"form-field-field_d3ae93f-1\" name=\"form_fields[field_d3ae93f][]\"> <label for=\"form-field-field_d3ae93f-1\">Crutches<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Wheelchair\" id=\"form-field-field_d3ae93f-2\" name=\"form_fields[field_d3ae93f][]\"> <label for=\"form-field-field_d3ae93f-2\">Wheelchair<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Walker\" id=\"form-field-field_d3ae93f-3\" name=\"form_fields[field_d3ae93f][]\"> <label for=\"form-field-field_d3ae93f-3\">Walker<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Special Cutlery\" id=\"form-field-field_d3ae93f-4\" name=\"form_fields[field_d3ae93f][]\"> <label for=\"form-field-field_d3ae93f-4\">Special Cutlery<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Special Chair \" id=\"form-field-field_d3ae93f-5\" name=\"form_fields[field_d3ae93f][]\"> <label for=\"form-field-field_d3ae93f-5\">Special Chair <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Adapted\" id=\"form-field-field_d3ae93f-6\" name=\"form_fields[field_d3ae93f][]\"> <label for=\"form-field-field_d3ae93f-6\">Adapted<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Others\" id=\"form-field-field_d3ae93f-7\" name=\"form_fields[field_d3ae93f][]\"> <label for=\"form-field-field_d3ae93f-7\">Others<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_064a5ed elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_064a5ed\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tList the medication you take\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_064a5ed]\" id=\"form-field-field_064a5ed\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8af7895 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8af7895\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAllergies?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8af7895]\" id=\"form-field-field_8af7895\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_52bf755 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_52bf755\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIn case of emergency, a Name and Contact Number (Preferably family)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_52bf755]\" id=\"form-field-field_52bf755\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Name and Phone Number\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Send<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Formulario M\u00e9dico<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-180","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/drjaimeponcedeleon.com.mx\/es\/wp-json\/wp\/v2\/pages\/180","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/drjaimeponcedeleon.com.mx\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/drjaimeponcedeleon.com.mx\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/drjaimeponcedeleon.com.mx\/es\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/drjaimeponcedeleon.com.mx\/es\/wp-json\/wp\/v2\/comments?post=180"}],"version-history":[{"count":0,"href":"https:\/\/drjaimeponcedeleon.com.mx\/es\/wp-json\/wp\/v2\/pages\/180\/revisions"}],"wp:attachment":[{"href":"https:\/\/drjaimeponcedeleon.com.mx\/es\/wp-json\/wp\/v2\/media?parent=180"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}