{"id":59377,"date":"2025-12-15T08:29:10","date_gmt":"2025-12-15T08:29:10","guid":{"rendered":"https:\/\/pmitsdev.com\/pasaporte2\/?page_id=59377"},"modified":"2026-01-29T13:34:29","modified_gmt":"2026-01-29T13:34:29","slug":"patient-registration","status":"publish","type":"page","link":"https:\/\/pmitsdev.com\/pasaporte2\/patient-registration\/","title":{"rendered":"Patient Registration"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"59377\" class=\"elementor elementor-59377\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-e2cb312 elementor-section-boxed elementor-section-height-default elementor-section-height-default sc_fly_static\" data-id=\"e2cb312\" data-element_type=\"section\" data-e-type=\"section\">\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-100 elementor-top-column elementor-element elementor-element-20ba294 sc_content_align_inherit sc_layouts_column_icons_position_left sc_fly_static\" data-id=\"20ba294\" 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-cc322c1 sc_fly_static elementor-widget elementor-widget-shortcode\" data-id=\"cc322c1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><!-- Just copy everything from your -->\n\n<section class=\"contact-section\">\n    <div class=\"container\">\n        <div class=\"row\">\n\n\t\t\t\t<div class=\"col-lg-12\">\n\t\t\t\t\t<nav class=\"navbar navbar-expand-lg navbar-light bg-light\">\n\t\t\t\t\t\t<button class=\"navbar-toggler\" type=\"button\" data-toggle=\"collapse\" data-target=\"#n\" aria-controls=\"n\" aria-expanded=\"false\">\n\t\t\t\t\t\t\t<span class=\"navbar-toggler-icon\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t\t\t\t<div class=\"mx-auto order-0\">\n\t\t\t\t\t\t\t<div class=\"collapse navbar-collapse\" id=\"n\">\n\t\t\t\t\t\t\t\t<div class=\"navbar-nav\">\n\t\t\t\t\t\t\t\t\t<a id=\"item1\" onclick=\"cambiarPagina(1)\" class=\"nav-item nav-link active\" href=\"#\">Page 1<\/a>\n\t\t\t\t\t\t\t\t\t<a id=\"item2\" onclick=\"cambiarPagina(2)\" class=\"nav-item nav-link\" href=\"#\">Page 2<\/a>\n\t\t\t\t\t\t\t\t\t<a id=\"item3\" onclick=\"cambiarPagina(3)\" class=\"nav-item nav-link\" href=\"#\">Page 3<\/a>\n\t\t\t\t\t\t\t\t\t<a id=\"item4\" onclick=\"cambiarPagina(4)\" class=\"nav-item nav-link\" href=\"#\">Page 4<\/a>\n\t\t\t\t\t\t\t\t\t<a id=\"item5\" onclick=\"cambiarPagina(5)\" class=\"nav-item nav-link\" href=\"#\">Page 5<\/a>\n\t\t\t\t\t\t\t\t\t<a id=\"item6\" onclick=\"cambiarPagina(6)\" class=\"nav-item nav-link\" href=\"#\">Page 6<\/a>\n\t\t\t\t\t\t\t\t\t<a id=\"item7\" onclick=\"cambiarPagina(7)\" class=\"nav-item nav-link\" href=\"#\">Page 7<\/a>\n\t\t\t\t\t\t\t\t\t<a id=\"item8\" onclick=\"cambiarPagina(8)\" class=\"nav-item nav-link\" href=\"#\">Page 8<\/a>\n\t\t\t\t\t\t\t\t\t<a id=\"item9\" onclick=\"cambiarPagina(9)\" class=\"nav-item nav-link\" href=\"#\">Page 9<\/a>\n\t\t\t\t\t\t<a id=\"item10\" onclick=\"cambiarPagina(10)\" class=\"nav-item nav-link\" href=\"#\">Request For Treatment<\/a>\n\t\t\t\t\t\t\t\t\t<a id=\"item11\" onclick=\"cambiarPagina(11)\" class=\"nav-item nav-link\" href=\"#\">Send Data<\/a>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/nav>\n\t\t\t\t\t<br>\n\n\t\t\t\t\t<div class=\"contact-text\">\n                        <h4>All Information Provided is Strictly Confidential<\/h4>\n                    <\/div>\n\t\t\t\t\t<form class=\"contact-form\" id=\"pagina1\" action=\"#\" style=\"display: block;\">\n\t\t\t\t\t\t<h4 style=\"color: #396B39;\">Patient information<\/h4>\n\t\t\t\t\t\t<br>\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-9\">\n\t\t\t\t\t\t\t\t<select id=\"idiomaP1\">\n\t\t\t\t\t\t\t\t\t<option selected=\"\" disabled=\"\">language<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Spanish\">Spanish<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"English\">English<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bilingual\">Bilingual<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-3\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"date\" id=\"fechaP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<select id=\"pacienteP1\">\n\t\t\t\t\t\t\t\t\t<option selected=\"\" disabled=\"\">Patient<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Mr.<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Mrs.<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Miss.<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">Dr\/Dra.<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-5\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Name(s)\" id=\"nombreP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-5\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"last name\" id=\"apellidoP1\">\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<select id=\"sexoP1\">\n\t\t\t\t\t\t\t\t\t<option selected=\"\" disabled=\"\">Gender<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Female<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Male<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<!--<div class=\"col-lg-4\">-->\n\t\t\t\t\t\t\t<!--\t<select id=\"embarazoP1\">-->\n\t\t\t\t\t\t\t<!--\t\t<option selected disabled> are you or might you be pregnant?<\/option>-->\n\t\t\t\t\t\t\t<!--\t\t<option value=\"2\">N\/A<\/option>-->\n\t\t\t\t\t\t\t<!--\t\t<option value=\"1\">Yes<\/option>-->\n\t\t\t\t\t\t\t<!--\t\t<option value=\"0\">No<\/option>-->\n\t\t\t\t\t\t\t<!--\t<\/select>-->\n\t\t\t\t\t\t\t<!--<\/div>-->\n\t\t\t\t\t\t\t<div class=\"col-lg-5\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Height\" id=\"estaturaP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-5\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"weight\" id=\"pesoP1\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<select id=\"civilP1\">\n\t\t\t\t\t\t\t\t\t<option selected=\"\" disabled=\"\">Marital status<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Single<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Married<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Separated<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">Widow\/Widower<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">Significant other<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5\">Divorced<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Date of birth\" id=\"fechaNacimientoP1\">\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-3\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Age\" id=\"edadP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-3\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Home number\" id=\"telefonoP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<h4><\/h4><br>\n\t\t\t\t\t\t<h4>Address<\/h4><br>\n\t\t\t\t\t\t\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Street address\" id=\"calleP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Suburb\" id=\"coloniaP1\">\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-3\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"City\" id=\"ciudadP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-3\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"State\" id=\"estadoP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Zip code\" id=\"codigoPostalP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"company where you work\" id=\"nombreEmpresaP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Job title\" id=\"puestoEmpresaP1\">\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-3\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Email\" id=\"emailP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-3\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"cell phone (XXX)XXX-XXXX\" id=\"telefonoCelularP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Work address\" id=\"domicilioTrabajoP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"City\" id=\"ciudadTrabajoP1\">\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-3\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"State\" id=\"estadoTrabajoP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-3\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Work phone\" id=\"telefonoTrabajoP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Spouse's name\" id=\"nombreEsposaP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Spouse's last name\" id=\"apellidoEsposaP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-3\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Spouse's workplace name\" id=\"nombreEmpresaEsposaP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Job title\" id=\"puestoEmpresaEsposaP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-3\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"spouse's workplace address\" id=\"domicilioTrabajoEsposaP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"City\" id=\"ciudadEsposaP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"work phone\" id=\"telefonoTrabajoEsposaP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t<h4>1st Child<\/h4>\n\t\t\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Name (s)\" id=\"nombreHijo1P1\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Age\" id=\"edadHijo1P1\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t<h4>2nd Child<\/h4>\n\t\t\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Name (s)\" id=\"nombreHijo2P1\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Age\" id=\"edadHijo2P1\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t<h4>3rd Child<\/h4>\n\t\t\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Name (s)\" id=\"nombreHijo3P1\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Age\" id=\"edadHijo3P1\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t<h4>4th Child<\/h4>\n\t\t\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Name (s)\" id=\"nombreHijo4P1\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Age\" id=\"edadHijo4P1\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t<h4>5th Child<\/h4>\n\t\t\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Name (s)\" id=\"nombreHijo5P1\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Age\" id=\"edadHijo5P1\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t<h4>6th Child<\/h4>\n\t\t\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Name (s)\" id=\"nombreHijo6P1\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Age\" id=\"edadHijo6P1\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\t\t\t\t\t\t<h4>If the patient is a minor or incapacitated, who is their legal guardian or representative?\n\t\t\t\t\t\t<\/h4>\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-5\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Name (s)\" id=\"nombreTutorP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-3\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Phone number\" id=\"telefonoTutorP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Address\" id=\"direccionTutorP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"row\">\n\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Suburb\" id=\"coloniaTutorP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"City\" id=\"ciudadTutorP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"State\" id=\"estadoTutorP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Zip code\" id=\"codigoPostalTutorP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Relationship\" id=\"relacionTutorP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<h4 style=\"color: #396B39;\">Emergency contact<\/h4>\n\t\t\t\t\t\t<!--<h4>Name of a person not living with you:<\/h4>-->\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"First name\" id=\"nombreContactoP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Last name\" id=\"apellidoContactoP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Relationship\" id=\"relacionContactoP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<h4>Address<\/h4>\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Street name\" id=\"calleContactoP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Suburb\" id=\"coloniaContactoP1\">\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"City\" id=\"ciudadContactoP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"State\" id=\"estadoContactoP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Zip code\" id=\"codigoPostalContactoP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Home number\" id=\"telefonoContactoP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Work number\" id=\"telefonoTrabajoContactoP1\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<br>\n\n\t\t\t\t\t\t<button type=\"button\" class=\"site-btn\" style=\"float: right;\" onclick=\"siguientePagina(1)\">Next page<\/button>\n\n\t\t\t\t\t\t<!--textarea placeholder=\"Message\"><\/textarea-->\n\t\t\t\t\t<\/form>\n\t\t\t\t\t\n\t\t\t\t\t<form class=\"contact-form\" id=\"pagina2\" style=\"display: none;\" action=\"#\">\n\t\t\t\t\t\t<h4 style=\"color: #396B39;\"> MAJOR COMPLAINT (by priority)<\/h4>\n\t\t\t\t\t\t<br>\n\t\t\t\t\t\t<h4>OTHER COMPLAINTS<\/h4>\n\t\t\t\t\t\t<h4 style=\"color: black;\">by priority\n\t\t\t\t\t\t<\/h4>\n\t\t\t\t\t\t<textarea id=\"problemas1P2\" style=\"height: 150px;\"><\/textarea>\n\t\t\t\t\t\t<input type=\"text\" placeholder=\"Date of onset (When you first noticed the problem?)\" id=\"fechaProblema1P2\">\n\n\t\t\t\t\t\t<select id=\"condicionProblema1P2\">\n\t\t\t\t\t\t\t<option selected=\"\" disabled=\"\">Is your condition<\/option>\n\t\t\t\t\t\t\t<option value=\"0\">Getting worse<\/option>\n\t\t\t\t\t\t\t<option value=\"1\">Constant<\/option>\n\t\t\t\t\t\t\t<option value=\"2\">Comes and goes<\/option>\n\t\t\t\t\t\t\t<option value=\"3\">Getting better<\/option>\n\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t<h4> Describe your pain from 0 up to 10 (0 no pain , 10 unbearable)<\/h4>\n\t\t\t\t\t\t<br>\n\n\t\t\t\t\t\t<div class=\"row\">\n\n\t\t\t\t\t\t\t<div class=\"col-lg-12\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero1P2\" id=\"radio1\" checked=\"\" value=\"0\"><label class=\"form-check-label\" for=\"radio1\"> 0 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero1P2\" id=\"radio2\" value=\"1\"><label class=\"form-check-label\" for=\"radio2\"> 1 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero1P2\" id=\"radio3\" value=\"2\"><label class=\"form-check-label\" for=\"radio3\"> 2 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero1P2\" id=\"radio4\" value=\"3\"><label class=\"form-check-label\" for=\"radio4\"> 3 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero1P2\" id=\"radio5\" value=\"4\"><label class=\"form-check-label\" for=\"radio5\"> 4 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero1P2\" id=\"radio6\" value=\"5\"><label class=\"form-check-label\" for=\"radio6\"> 5 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero1P2\" id=\"radio7\" value=\"6\"><label class=\"form-check-label\" for=\"radio7\"> 6 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero1P2\" id=\"radio8\" value=\"7\"><label class=\"form-check-label\" for=\"radio8\"> 7 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero1P2\" id=\"radio9\" value=\"8\"><label class=\"form-check-label\" for=\"radio9\"> 8 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero1P2\" id=\"radio10\" value=\"9\"><label class=\"form-check-label\" for=\"radio10\"> 9 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero1P2\" id=\"radio11\" value=\"10\"><label class=\"form-check-label\" for=\"radio11\"> 10 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\t\t\t\t\t\t<h4>Other diseases:(problems)<\/h4>\n\t\t\t\t\t\t<textarea id=\"problemas2P2\" style=\"height: 150px;\"><\/textarea>\n\n\t\t\t\t\t\t<input type=\"text\" placeholder=\"Date of onset (when you first noticed the problem )\" id=\"fechaProblema2P2\">\n\n\t\t\t\t\t\t<select id=\"condicionProblema2P2\">\n\t\t\t\t\t\t\t<option selected=\"\" disabled=\"\">Is your codition<\/option>\n\t\t\t\t\t\t\t<option value=\"0\">Getting worse<\/option>\n\t\t\t\t\t\t\t<option value=\"1\">Constant<\/option>\n\t\t\t\t\t\t\t<option value=\"2\">Comes and goes<\/option>\n\t\t\t\t\t\t\t<option value=\"3\">Getting better<\/option>\n\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t<h4> Describe your pain from 0 up to 10 (0 no pain , 10 unbearable)<\/h4>\n\n\t\t\t\t\t\t<br>\n\n\t\t\t\t\t\t<div class=\"row\">\n\n\t\t\t\t\t\t\t<div class=\"col-lg-12\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero2P2\" id=\"radio12\" checked=\"\" value=\"0\"><label class=\"form-check-label\" for=\"radio12\"> 0 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero2P2\" id=\"radio13\" value=\"1\"><label class=\"form-check-label\" for=\"radio13\"> 1 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero2P2\" id=\"radio14\" value=\"2\"><label class=\"form-check-label\" for=\"radio14\"> 2 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero2P2\" id=\"radio15\" value=\"3\"><label class=\"form-check-label\" for=\"radio15\"> 3 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero2P2\" id=\"radio16\" value=\"4\"><label class=\"form-check-label\" for=\"radio16\"> 4 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero2P2\" id=\"radio17\" value=\"5\"><label class=\"form-check-label\" for=\"radio17\"> 5 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero2P2\" id=\"radio18\" value=\"6\"><label class=\"form-check-label\" for=\"radio18\"> 6 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero2P2\" id=\"radio19\" value=\"7\"><label class=\"form-check-label\" for=\"radio19\"> 7 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero2P2\" id=\"radio20\" value=\"8\"><label class=\"form-check-label\" for=\"radio20\"> 8 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero2P2\" id=\"radio21\" value=\"9\"><label class=\"form-check-label\" for=\"radio21\"> 9 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"form-check form-check-inline\">\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"radio\" name=\"condicionNumero2P2\" id=\"radio22\" value=\"10\"><label class=\"form-check-label\" for=\"radio22\"> 10 <\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"date of the last physical exam?\" id=\"fechaExamenP2\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Doctor's name\" id=\"nombreDoctorP2\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t<select id=\"tratamientoP2\">\n\t\t\t\t\t\t\t\t\t<option selected=\"\" disabled=\"\">Are you being treated by a doctor now?<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">No<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-6\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Diagnosis\" id=\"diagnosticoP2\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<h4 style=\"color: red;\"><b>THINGS TO BRING WITH YOU TO YOUR FIRST APPOINTMENT:<br>\n\t\t\t\t\t\t\t\t1. \"Patient information\" form filled out completely.<br>\n\t\t\t\t\t\t\t\t2. Bring X-rays, laboratory reports, blood tests, doctor's reports etc.<br>\n\t\t\t\t\t\t\t\t3. Bring (in their original containers) all medications you are currently taking.<br>\n\t\t\t\t\t\t\t\t4. Bring (in their original containers) all supplements, herbs, etc. you are currently taking.<br>\n\t\t\t\t\t\t\t<\/b><\/h4>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<select id=\"recomendacionP2\">\n\t\t\t\t\t\t\t\t\t<option selected=\"\" value=\"\">who recommended you to our clinic?<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Spouse(o)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Relatives<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Friend<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">Work<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">Doctor(a)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5\">social media<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6\">Publicity (our web page)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7\">Other<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Referred by:\" id=\"nombreReferidoP2\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Phone\" id=\"relacionReferidoP2\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Address\" id=\"direccionReferidoP2\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"City\" id=\"ciudadReferidoP2\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"State\" id=\"estadoReferidoP2\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<h4>Nutrition and lifestyles<\/h4>\n\t\t\t\t\t\t<br>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tDo you eat\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkComida1P8\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tBreakfast\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"What time?\" id=\"horaDesayunoP8\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkComida2P8\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tLunch\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"What time?\" id=\"horaComidaP8\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkComida3P8\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tDinner\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"What time?\" id=\"horaCenaP8\">\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkComida4P8\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tSnack Between meals\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"What time?\" id=\"horaEntreComidasP8\">\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tNo. glasses consumed daily\n\n\t\t\t\t\t\t\t<\/label>\n\n\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Water\" id=\"numeroAguaP8\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Coffe\" id=\"numeroCafeP8\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Soda\" id=\"numeroColaP8\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Milk\" id=\"numeroLecheP8\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Other\" id=\"numeroOtraBebidaP8\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-3 col-form-label\">\n\n\t\t\t\t\t\t\t\tDo you use alcohol?\n\n\t\t\t\t\t\t\t<\/label>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"alcoholP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tYes\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">No<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Amount per week\" id=\"cantidadAlcoholP8\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"Type\" id=\"tipoAlcoholP8\">\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-3 col-form-label\">\n\n\t\t\t\t\t\t\t\tDo you use tobacco\n\n\t\t\t\t\t\t\t<\/label>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"fumaP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tYes\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tNo\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"No. of packs per day\" id=\"cajetillasDiaP8\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-lg-4\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"No. of years\" id=\"numeroAnosP8\">\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<button type=\"button\" class=\"site-btn\" style=\"float: right;\" onclick=\"siguientePagina(2)\">Next page<\/button>\n\t\t\t\t\t\t<button type=\"button\" class=\"site-btn\" style=\"float: left;\" onclick=\"anteriorPagina(2)\">Previous page<\/button>\n\n\t\t\t\t\t<\/form>\n\n\t\t\t\t\t<form class=\"contact-form\" id=\"pagina3\" action=\"#\" style=\"display: none;\">\n\t\t\t\t\t\t<h4 style=\"color: #396B39;\"> Medical History<\/h4>\n\t\t\t\t\t\t<h4>patient symptom survey<\/h4>\n\t\t\t\t\t\t<br>\n\t\t\t\t\t\t<h4 style=\"color: black;\">The information you provide is strictly confidential.<br>\n\t\t\t\t\t\t\tPlease check any condition you Now have <strong> Now (N)<\/strong>,or have had in the Past (more than 12 months)\n\t\t\t\t\t\t\t<strong>past(P)<\/strong> <strong>Now and Past (N and P)<\/strong>.<\/h4>\n\n\t\t\t\t\t\t<br>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Diabetes<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"diabetesP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and Past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Heart problems<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"problemaCorazonP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">Liver disease<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"liverdiseaseP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">High blood pressure<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"presionSanguineaAltaP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Stroke\/CVA<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"infartoP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">Kidney disease<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"enfermedadRinionP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Low blood pressure<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"presionSanguineaBajaP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Past and now<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Cardiac Surgery<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"cirugiaCardiacaP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and Past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">Gallbladder disorder<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"problemasVesiculaP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Bleeding disorders<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"desordenesSangradoP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Pacemaker<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"marcapasosP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> digestive disorders<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"problemasDigestivosP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Cancer<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"cancerP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Organ transplantation<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"transplanteOrganoP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">Artificial joints<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"articulacionesArtificialesP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Lupus<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"lupusP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Arthritis\/Rheumatism<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"artitrisReumatismoP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">Asthma\/Bronchitis<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"asmaBronquitisP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Anemia<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"anemiaP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Convulsions\/Seizures<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"convulsionesAtaquesP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> Ulcers<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"ulcerasP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Thyroid problem<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"problemaTiroidesP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Mental disorder<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"desordenesMentalesP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> Urinary bladder problem<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"problemasVejigaP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Weight gain <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"aumentoPesoP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Paralysis<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"paralisisP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> chronic fatigue<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"fatigaCronicaP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> weight loss <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"perdidaPesoP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Tremors<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"tembloresP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">Fainting spells <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"desmayosP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Emphysema <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"enfisemaP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Tuberculosis<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"tuberculosisP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> Embolism<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"emboliasP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Osteoporosis<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"osteoporosisP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Escoliosis<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"escoliosisP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">Prostate disorder <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"desordenProstataP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Sexually transmitted disease\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"enfermedadSexualP3\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"otroP3\" placeholder=\"Other symptom survey\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<h4>Family History<\/h4><br>\n\t\t\t\t\t\t<h4 style=\"color: black;\">Has any member of your family had any of the above conditions?\n\n\t\t\t\t\t\t<\/h4><br>\n\n\t\t\t\t\t\t<select id=\"historiaFamiliarSelectP3\">\n\t\t\t\t\t\t    <option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t<option value=\"0\">No<\/option>\n\t\t\t\t\t\t\t<option value=\"1\">Yes<\/option>\n\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t<h4 style=\"color: black;\"> If yes - Which family member and what did they have?<\/h4>\n\n\t\t\t\t\t\t<textarea id=\"historiaFamiliarTextoP3\" style=\"height: 150px;\"><\/textarea>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\t\t\t\t\t\t<h4>Accidents, Falls , Broken bones<\/h4><br>\n\t\t\t\t\t\t<h4 style=\"color: black;\">Have you been in any car accidents, fallen and\/or broken bones, or suffered other traumas resulting in injuries? Please list the date and event, starting with the most recent.<\/h4><br>\n\n\t\t\t\t\t\t<textarea id=\"accidentesTextoP3\" style=\"height: 150px;\"><\/textarea>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<h4>Surgeries, Medical Procedures<\/h4><br>\n\t\t\t\t\t\t<h4 style=\"color: black;\">Please list them, along with the dates, starting with the most recent. Have you been advised to undergo surgical procedures that you have not had? <\/h4><br>\n\n\t\t\t\t\t\t<select id=\"cirugiasSelectP3\">\n\t\t\t\t\t\t    <option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t<option value=\"0\">No<\/option>\n\t\t\t\t\t\t\t<option value=\"1\">Yes<\/option>\n\t\t\t\t\t\t<\/select>\n\n\n\t\t\t\t\t\t<textarea id=\"cirugiasTextoP3\" style=\"height: 150px;\"><\/textarea>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<h4>Medications,Drugs,Herbs or supplements<\/h4><br>\n\t\t\t\t\t\t<h4 style=\"color: black;\">Please list the Medication by Name \/ dosage in mg.\/mcg., etc. \/ how often (AM-Noon-PM) as 1-0-1, etc. \/ how long taking (# weeks, or # months, # years, etc.)\n\t\t\t\t\t\t<\/h4><br>\n\n\t\t\t\t\t\t<select id=\"medicamentosSelectP3\">\n\t\t\t\t\t\t    <option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t<option value=\"0\">No<\/option>\n\t\t\t\t\t\t\t<option value=\"1\">Yes<\/option>\n\t\t\t\t\t\t<\/select>\n\n\n\t\t\t\t\t\t<textarea id=\"medicamentosTextoP3\" style=\"height: 150px;\"><\/textarea>\n\n\t\t\t\t\t\t<button type=\"button\" class=\"site-btn\" style=\"float: right;\" onclick=\"siguientePagina(3)\">Next page<\/button>\n\t\t\t\t\t\t<button type=\"button\" class=\"site-btn\" style=\"float: left;\" onclick=\"anteriorPagina(3)\">Previous page<\/button>\n\n\t\t\t\t\t<\/form>\n\n\t\t\t\t\t<form class=\"contact-form\" id=\"pagina4\" action=\"#\" style=\"display: none;\">\n\t\t\t\t\t    \n\t\t\t\t\t    \n\t\t\t\t\t    <table style=\"width: 100%; text-align: center; margin-bottom: 40px;\">\n\t\t\t\t\t\t\t<tr>\n\t\t\t\t\t\t\t\t<td><h4 style=\"text-align: center; font-size: 15px; padding: 15px\">Medication Name<\/h4><\/td>\n\t\t\t\t\t\t\t\t<td><h4 style=\"text-align: center; font-size: 15px; padding: 15px\">Dosage in mg<\/h4><\/td>\n\t\t\t\t\t\t\t\t<td><h4 style=\"text-align: center; font-size: 15px; padding: 15px\">How often do you take the medication?<\/h4><\/td>\n\t\t\t\t\t\t\t\t<td><h4 style=\"text-align: center; font-size: 15px; padding: 15px\">How long have you been taking the medication?<\/h4><\/td>\n\t\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t\t<tr>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"medName1\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"doseage1\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howOften1\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howLong1\" \/><\/td>\n\t\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t\t<tr>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"medName2\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"doseage2\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howOften2\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howLong2\" \/><\/td>\n\t\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t\t<tr>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"medName3\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"doseage3\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howOften3\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howLong3\" \/><\/td>\n\t\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t\t<tr>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"medName4\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"doseage4\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howOften4\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howLong4\" \/><\/td>\n\t\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t\t<tr>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"medName5\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"doseage5\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howOften5\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howLong5\" \/><\/td>\n\t\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t\t<tr>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"medName6\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"doseage6\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howOften6\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howLong6\" \/><\/td>\n\t\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t\t<tr>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"medName7\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"doseage7\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howOften7\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howLong7\" \/><\/td>\n\t\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t\t<tr>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"medName8\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"doseage8\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howOften8\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howLong8\" \/><\/td>\n\t\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t\t<tr>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"medName9\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"doseage9\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howOften9\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howLong9\" \/><\/td>\n\t\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t\t<tr>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"medName10\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"doseage10\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howOften10\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howLong10\" \/><\/td>\n\t\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t\t<tr>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"medName11\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"doseage11\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howOften11\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howLong11\" \/><\/td>\n\t\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t\t<tr>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"medName12\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"doseage12\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howOften12\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howLong12\" \/><\/td>\n\t\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t\t<tr>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"medName13\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"doseage13\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howOften13\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howLong13\" \/><\/td>\n\t\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t\t<tr>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"medName14\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"doseage14\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howOften14\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howLong14\" \/><\/td>\n\t\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t\t<tr>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"medName15\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"doseage15\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howOften15\" \/><\/td>\n\t\t\t\t\t\t\t\t<td><input type=\"text\" id=\"howLong15\" \/><\/td>\n\t\t\t\t\t\t\t<\/tr>\n\t\t\t\t\t\t<\/table>\n\t\t\t\t\t    \n\t\t\t\t\t    \n\t\t\t\t\t\t<button type=\"button\" class=\"site-btn\" style=\"float: right;\" onclick=\"siguientePagina(4)\">Next page<\/button>\n\t\t\t\t\t\t<button type=\"button\" class=\"site-btn\" style=\"float: left;\" onclick=\"anteriorPagina(4)\">Previous pag<\/button>\n\n\n\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t<\/form>\n\n\t\t\t\t\t<form class=\"contact-form\" id=\"pagina5\" action=\"#\" style=\"display: none;\">\n<h4>\n\n\t\t\t\t\t\t\tMental, Emotional and neurological\n\n\t\t\t\t\t\t<\/h4>\n\t\t\t\t\t\t<br>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Nervousness <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"nerviosismoP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Easily Angered <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"enojoFacilP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tPoor concentration\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"concentracionPobreP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Depression <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"depresionP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tMood swings\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"cambiosHumorP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tMental confusion\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"confusionMentalP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tWorry \/ Anxiety\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"preocupacionAnsiedadP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tFrequent crying\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"llantoFrecuenteP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tPoor coordination\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"coordinacionPObreP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tSuicidal\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"suicidaP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tNeuralgia (nerve pain)\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"neuralgiaP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tTremors\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"tembloresP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Grief\/grieving <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"penaLamentacionP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tFear \/ Fearful\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"miedoP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tIndecision\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"evacuacionDolorosaP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Stress problems <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"estresP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> heat or Cold intolerance <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"intoleranciaCalienteFrioP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tChronic fatigue\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"fatigaCronicaP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tNumbness\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"entumecimientoP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Pins\/needles sensation <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"sensacionPicazonP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tIrritability \/ Tension\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"irratabilidadTensionP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tParalysis\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"paralisisP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tCramps \/ Spasms\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"calambresEspasmosP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> Tics \/ Tremors <\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"ticsTemblorinasP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tMental disorders\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"desordenesMentalesP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tNervous breakdown\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"crisisNerviosaP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tBipolar disorder\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"desordenBipolarP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tSleep problems\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"problemasSuenoP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkSueno1P8\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tTrouble falling asleep\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkSueno2P8\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tTrouble staying asleep\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkSueno3P8\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tRestful\n\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkSueno4P8\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tWake up from sleep short of breath\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkSueno5P8\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tSnore\n\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkSueno6P8\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tExcess dreaming\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkSueno7P8\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tWake up tired\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkSueno8P8\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tWake up refresh\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-6\">\n\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"horasDuermeP8\" placeholder=\"How many hours do you sleep?\">\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tStress level (0 no stress, 10 unbearable stress)\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-4\">\n\n\t\t\t\t\t\t\t\t<select id=\"nivelEstresP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"0\">0<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">1<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">2<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">3<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">4<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5\">5<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6\">6<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7\">7<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"8\">8<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"9\">9<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10\">10<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"causaEstresP8\" placeholder=\"What causes stress\">\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tAddiction to:\n\n\t\t\t\t\t\t\t<\/label>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkAdiccion1P8\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\t\t\t\t\t\t\t\t\t\tAlcohol\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkAdiccion2P8\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tTobacco\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkAdiccion3P8\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tRecreational drugs\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkAdiccion4P8\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tMedications\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"adiccionP8\" placeholder=\"Other\">\n\n\t\t\t\t\t\t\t<\/div>\n\n\n\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n<h4>\n\n\t\t\t\t\t\t\tFemale Reproductive system\n\n\t\t\t\t\t\t<\/h4>\n\t\t\t\t\t\t<br>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-6\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"diasSangradoP7\" placeholder=\"No. days of bleeding\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tBlood color\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-4\">\n\n\t\t\t\t\t\t\t\t<select id=\"colorSangreP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tBright red\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tDark red\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tLight red (watery)\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tAre you pregnant now?\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-4\">\n\n\t\t\t\t\t\t\t\t<select id=\"embarazadaAhoraP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tYes\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">No<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tAre you breast feeding now?\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-4\">\n\n\t\t\t\t\t\t\t\t<select id=\"amamantandoP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tYes\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">No<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-6\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"primerDiaUltimoMenstruacionP7\" placeholder=\"First day of last period\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-6\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"ultimaMamografiaP7\" placeholder=\"Last mammogram\">\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-6\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"examenGinecologoP7\" placeholder=\"Last OB \/ Gynecologist exam\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-6\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"doctorP7\" placeholder=\"Doctor\">\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-6\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"edadCicloP7\" placeholder=\"Age started menstrual cycle\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-6\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"edadDetuvoP7\" placeholder=\"Age stopped\">\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tMenstrual pain\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorMenstrualP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Heavy bleeding <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"sangradoAbundanteP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tRegular cycle\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"cicloNormalP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Blood clots <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"coagulosP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Light\/scanty bleeding <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"sangradoEscasoP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tIrregular cycle\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"cicloIrregular\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Breast pain <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorPechosP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Mood swings <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"cambiosHumorP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> Skip periods <\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"brincanPeriodosP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Headache <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorCabezaP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Water retention <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"retencionAguaP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tHot flashes\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"bochornosP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tLow back pain\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorEspaldaBajaP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Angry\/emotional <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"emocionalmenteEnojadaP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> Food cravings <\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"hambreDesesperanteP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tLow sex drive\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"bajoLibidoMujerP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tSexually transmitted disease\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"enfermedadVenereaP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tHIV \/ AIDS\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"vihSidaMujerP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Breast lumps\/cysts <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"quistePechoP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tUterine cyst \/ tumor\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"quisteTumorUterinoP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> Painful ovaries <\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorOvariosP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Pre-menopause <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"preMenopausiaP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> menopause <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"menopausiaP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tHormone therapy\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"terapiaHormonaP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Fibrocystic breasts <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"quisteFibrosoPechoP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\"> Cysts on ovaries or uterus <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<select id=\"quisteOvarioP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"quisteOvarioLugarP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">R<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">L<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Both<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tGenital infection\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"infeccionGenitalMujerP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Painful intercourse <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorRelacionP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tEndometrosis\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"endometrosisP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tVaginal discharge\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"desechoVaginalP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkDesecho1P7\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tWhite\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkDesecho2P7\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tYellow\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkDesecho3P7\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tThick\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkDesecho4P7\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tWatery\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkDesecho5P7\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\t\t\t\t\t\t\t\t\t\tOdor\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkDesecho6P7\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tItchying\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-lg-3\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"No. of pregnancies\" id=\"numeroEmbarazosP7\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"No. of deliveries\" id=\"numeroPartosP7\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"No. miscarriages\" id=\"numeroNoNacidosP7\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"No. of abortions\" id=\"numeroAbortosP7\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-lg-3\">\n\t\t\t\t\t\t\t\t<input type=\"text\" placeholder=\"No. of caesareans\" id=\"numeroCesareasP7\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tSurgeries:\n\n\t\t\t\t\t\t\t<\/label>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkCirugias1P7\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\t\t\t\t\t\t\t\t\t\tCervix\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkCirugias2P7\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tUterus\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkCirugias3P7\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tOvaries\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tBirth control\n\n\t\t\t\t\t\t\t<\/label>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkAnticonceptivos1P7\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tPills\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkAnticonceptivos2P7\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tSurgery\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"sistemaMujerOtroP7\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\n                        <button type=\"button\" class=\"site-btn\" style=\"float: right;\" onclick=\"siguientePagina(5)\">Next page<\/button>\n                        <button type=\"button\" class=\"site-btn\" style=\"float: left;\" onclick=\"anteriorPagina(5)\">Previous page<\/button>\n\n\t\t\t\t\t\n\t\t\t\t\t<\/form>\n\n\t\t\t\t\t<form class=\"contact-form\" id=\"pagina6\" action=\"#\" style=\"display: none;\">\n<h4>\n\n\t\t\t\t\t\t\tMale reproductive system\n\n\t\t\t\t\t\t<\/h4>\n\t\t\t\t\t\t<br>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tProstate problems\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"problemasProstataP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tErectile dysfunction\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"disfuncionErectilP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> Pain when urinating <\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorOrinarP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tDribbling after urination\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"goteoOrinarP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tLow sex drive\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"bajoLibidoHombreP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> Unusual discharge <\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"desechoInusualP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tProstate surgery\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"cirugiaProstataP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tImpotence\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"impotenciaP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tGenital infections\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"infeccionesGenitalesHombreP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tPremature ejaculation\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"eyaculacionPrematuraP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tSexually transmitted disease\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"enfermedadFuerteP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tHIV\/AIDS\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"vihSidaHombreP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"masculinoOtroP7\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n<h4>\n\n\t\t\t\t\t\t\tNutrition and lifestyles\n\n\t\t\t\t\t\t<\/h4>\n\n\t\t\t\t\t\t<br>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-10 col-form-label\">\n\t\t\t\t\t\t\t\tDo you plan your meals using the four basic food groups?\n\n\t\t\t\t\t\t\t<\/label>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\t\t\t\t\t\t\t\t<select id=\"pregunta1P9\">\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">No<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-10 col-form-label\">\n\t\t\t\t\t\t\t\tDo you eat raw fruit or vegetables at least twice a day?\n\n\t\t\t\t\t\t\t<\/label>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\t\t\t\t\t\t\t\t<select id=\"pregunta2P9\">\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tNo\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-10 col-form-label\">\n\n\t\t\t\t\t\t\t\tDo you eat green or yellow vegetables at least twice a day?\n\n\t\t\t\t\t\t\t<\/label>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\t\t\t\t\t\t\t\t<select id=\"pregunta3P9\">\n\t\t\t\t\t\t\t\t\t<option value=\"0\">yes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tNo\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-10 col-form-label\">\n\n\t\t\t\t\t\t\t\tDo you chew your food thoroughly before swallowing it?\n\n\t\t\t\t\t\t\t<\/label>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\t\t\t\t\t\t\t\t<select id=\"pregunta4P9\">\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tYes\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tNo\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-10 col-form-label\">\n\n\t\t\t\t\t\t\t\tDo you chew gum regularly \/ often?\n\n\t\t\t\t\t\t\t<\/label>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\t\t\t\t\t\t\t\t<select id=\"pregunta5P9\">\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tYes\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tNo\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-10 col-form-label\">\n\n\t\t\t\t\t\t\t\tDo you eat often between meals?\n\n\t\t\t\t\t\t\t<\/label>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\t\t\t\t\t\t\t\t<select id=\"pregunta6P9\">\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tYes\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tNo\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-10 col-form-label\">\n\n\t\t\t\t\t\t\t\tDo you eat meat daily and\/or dairy products two or more times per day?\n\n\t\t\t\t\t\t\t<\/label>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\t\t\t\t\t\t\t\t<select id=\"pregunta7P9\">\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tYes\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tNo\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-10 col-form-label\">\n\n\t\t\t\t\t\t\t\tDo you exercise or walk 30 minutes a day, 4 days per week or more?\n\n\t\t\t\t\t\t\t<\/label>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\t\t\t\t\t\t\t\t<select id=\"pregunta8P9\">\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tYes\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tNo\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-10 col-form-label\">\n\n\t\t\t\t\t\t\t\tDo you take vitamins, minerals, or other supplements?\n\n\t\t\t\t\t\t\t<\/label>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\t\t\t\t\t\t\t\t<select id=\"pregunta9P9\">\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tYes\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tNo\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\t\t\t\t\t\t<br>\n\n\t\t\t\t\t\t<h4>\n\n\t\t\t\t\t\t\tOften people have concerns about their health but are too embarrassed or afraid to ask.\n\n\t\t\t\t\t\t<\/h4><br>\n\t\t\t\t\t\t<h4 style=\"color: black;\">\n\n\t\t\t\t\t\t\tDo you have any questions or concerns about:\n\n\t\t\t\t\t\t<\/h4><br>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkPreocupacion1P9\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tCancer\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkPreocupacion2P9\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tHeart disease\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkPreocupacion3P9\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tAddictions\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkPreocupacion4P9\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tSexual issues or dysfunction\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\t\t\t\t\t\t<br>\n\n\t\t\t\t\t\t<textarea id=\"otroPreocupacionP9\" style=\"height: 150px;\" placeholder=\"Other\"><\/textarea>\n\t\t\t\t\t\t<textarea id=\"metasPersonalesP9\" style=\"height: 150px;\" placeholder=\"What are your main health and personal goals at this time?\"><\/textarea>\n\n\t\t\t\t\t\t<h4> How do you feel about the following areas of your life?: Please tick the space that applies. <\/h4><br>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Spouse\/significant other <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"esposaP9\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Great<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Good<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Regular<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">Poor<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">bad<\/option>\n\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-8\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"esposaTextoP9\" placeholder=\"Comments\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tFamily \/ home life\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"familiaP9\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Great<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Good<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Fair<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">Poor<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">\n\t\t\t\t\t\t\t\t\t\tbad<\/option>\n\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-8\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"familiaTextoP9\" placeholder=\"Comments\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tDiet\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"alimentacionP9\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Great<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Good<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Fair<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">poor<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">bad<\/option>\n\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-8\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"alimentacionTextoP9\" placeholder=\"Comments\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tExercise\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"ejercicioP9\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Great<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Good<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Fair<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">Poor<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">bad<\/option>\n\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-8\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"ejercicioTextoP9\" placeholder=\"Comments\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tSex\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"sexoP9\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Great<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Good<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Fair<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">Poor<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">bad<\/option>\n\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-8\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"sexoTextoP9\" placeholder=\"Comments\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Self-image <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"ustedP9\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Great<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Good<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Fair<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">Poor<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">bad<\/option>\n\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-8\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"ustedTextoP9\" placeholder=\"Comments\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Occupation\/Work <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"ocupacionTrabajoP9\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Great<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Good<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Fair<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">Poor<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">bad<\/option>\n\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-8\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"ocupacionTrabajoTextoP9\" placeholder=\"Comments\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\n                        <button type=\"button\" class=\"site-btn\" style=\"float: right;\" onclick=\"siguientePagina(6)\">Next page<\/button>\n                        <button type=\"button\" class=\"site-btn\" style=\"float: left;\" onclick=\"anteriorPagina(6)\">Previous page<\/button>\n\n\t\t\t\t\t\n\t\t\t\t\t<\/form>\n\n\t\t\t\t\t<form class=\"contact-form\" id=\"pagina7\" action=\"#\" style=\"display: none;\">\n<h4 style=\"color: #396B39;\"> External\/skeletal Exam<\/h4>\n\n<h4>Head<\/h4>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Headache <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorCabezaP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Migraine<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"migraniaP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> Head feels heavy<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"pesadezCabezaP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"row\">\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkCabeza1P4\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\t\t\t\t\t\t\t\t\t\tEntire head\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkMigrana1P4\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\t\t\t\t\t\t\t\t\t\tAura\/specks of light\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Light-headedness<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"mareosP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"row\">\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkCabeza2P4\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\t\t\t\t\t\t\t\t\t\tBack of the head\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkMigrana2P4\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\t\t\t\t\t\t\t\t\t\tAversion to light\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Memory loss<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"perdidaMemoriaP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"row\">\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkCabeza3P4\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\t\t\t\t\t\t\t\t\t\tForehead\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkMigrana3P4\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\t\t\t\t\t\t\t\t\t\tAversion to noise\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Fainting<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"desmayoP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"row\">\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"0\" id=\"checkCabeza4P4\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\t\t\t\t\t\t\t\t\t\tTemples\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkNausea4P4\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\t\t\t\t\t\t\t\t\t\tNausea\/vomiting\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Loss of balance<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"perdidaBalanceP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Loss of taste <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"perdidaSaborP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Dizziness\/vertigo<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"mareosVertigoP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">TMJ problems <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorMandibulaP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">False teeth\/dentures <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dentaduraP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Dental problems<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"problemasDentalesP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> Gum disease<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"enfermedadEnciasP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"cabezaOtroP4\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<h4>Eyes<\/h4>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Eye pain <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorOjoP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Dry eyes<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"ojosSecosP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> Glaucoma<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"glaucomaP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Blurred vision<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"visionBorrosaP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Tearing<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"lagrimeoP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">Wears glasses\/contact lenses <\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"luzOjosP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"ojosOtroP4\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"examenOjosP4\" placeholder=\"Date of last eye exam\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<h4>Nose<\/h4>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Sinusitis problems <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"sinusitisP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Frequent nosebleeds <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"sangradoNarizP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">Frequent colds <\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"resfriadoFrecuenteP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Loss of smell <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"perdidaOlfatoP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"otroNarizP4\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\n\t\t\t\t\t\t<h4>Ears<\/h4>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Ringing\/buzzing in ears <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorOidoP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">Ear discharge <\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"desechoOidoP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Poor hearing <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"audicionPobreP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Uses a hearing aid<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"aparatoAuditivoP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"otroOidosP4\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<h4>Neck\/Throat<\/h4>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Neck pain <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorCuelloP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Cervical trauma<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"traumatismoCervicalP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">Sore throat <\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"gargantaIrritadaP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Stiff neck <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"cuelloRigidoP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Herniated disc <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"discoHerniadoP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">Hoarseness <\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"carrasperaP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Popping sounds <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"sonidosTronidoP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Difficulty swallowing<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dificultadTragarP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> Jaw problems <\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"problemasMandibulaP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past <\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Tooth\/gum problems <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"problemasEnciaP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Sleep on your stomach <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"duermeBocabajoP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> Tight jaw <\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"mandibulaApretadaP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Enlarged thyroid <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"tiroidesAgrandadaP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Swollen glands<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"glandulasInflamadasP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">Neck surgery <\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"cirugiaCuelloP4\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"otroCuelloGargantaTextoP4\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n<h4>\n\n\t\t\t\t\t\t\tShoulders\n\n\t\t\t\t\t\t<\/h4>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tPain in shoulder joint\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorArticulacionHombroP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tPain across shoulders\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorHombrosP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tTension in shoulder\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"tensionHombrosP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tCan't raise arm\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"levantarBrazoP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tMuscle spasms in the shoulder\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"espasmoHombrosP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tThe problem is in\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"hombrosProblemaEnP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"row\">\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkLevantarBrazo1P5\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tAbove shoulder\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Tendonitis\/Bursitis <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"tendonitisBursitisP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkProblemaEsEnHombros1P5\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tRight shoulder\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"row\">\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkLevantarBrazo2P5\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tOver head\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkProblemaEsEnHombros2P5\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tLeft shoulder\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"hombrosOtroP5\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\n                        <button type=\"button\" class=\"site-btn\" style=\"float: right;\" onclick=\"siguientePagina(7)\">Next page<\/button>\n                        <button type=\"button\" class=\"site-btn\" style=\"float: left;\" onclick=\"anteriorPagina(7)\">Previous page<\/button>\n\n\t\t\t\t\t\n\t\t\t\t\t<\/form>\n\n\t\t\t\t\t<form class=\"contact-form\" id=\"pagina8\" action=\"#\" style=\"display: none;\">\n<h4>\n\n\t\t\t\t\t\t\tArms, elbows, wrists and hands\n\n\t\t\t\t\t\t<\/h4><br>\n\t\t\t\t\t\t<h4 style=\"color: black;\">\n\n\t\t\t\t\t\t\tPlease select \"R\" (right), \"L\" (left) or \"A\" (both)\n\n\t\t\t\t\t\t<\/h4>\n\t\t\t\t\t\t<br>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tPain in upper arm R\/L\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorAntebrazoP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dolorAntebrazoLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">R<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">L<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">both<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tPain in elbow R\/L\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorCodoP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">Now<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">Past<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">Now and past<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dolorCodoLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tPain in hands R\/L\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorManoP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dolorManoLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tPain in lower arm R\/L\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorBajoP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dolorBajoLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">R<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">L<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">both<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tPain in wrist R\/L\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorMunecaP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dolorMunecaLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tToe pain R\/L\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorDedosP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dolorDedosLugar\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tNumbness\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<select id=\"entumecimientoP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"entumecimientoLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tPins & needles sensation R\/L\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"sensacionHormigueoP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"sensacionHormigueoLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tCold hands\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"manosFriasP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"manosFriasLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tLoss of strength to squeeze\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"perdidaFuerzaApretarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"perdidaFuerzaApretarLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tCarpal tunnel syndrome\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"sindromeCarpoP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"sindromeCarpoLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tHot hands\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"manosCalientesP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"manosCalientesLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"brazosCodoOtroP5\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n<h4>\n\n\t\t\t\t\t\t\tBack\n\n\t\t\t\t\t\t<\/h4>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tUpper back pain\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorEspaldaAltaP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tMid back pain\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorEspaldaMediaP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tLow back pain\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorEspaldaBajaP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"row\">\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkEspaldaAlta1P5\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tBetween the shoulders\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkEspaldaMedia1P5\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tSharp stabbing pain\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkEspaldaBaja1P5\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tHerniated disc\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"row\">\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkEspaldaAlta2P5\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tMuscle spasms\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkEspaldaMedia2P5\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tMuscle spasms\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkEspaldaBaja2P5\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tMuscle spasms\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkEspaldaAlta3P5\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tThe pain is severe\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t\t<div class=\"col-md-4\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkEspaldaMedia3P5\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tThe pain is severe\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t\t<div class=\"col-md-3\">\n\n\t\t\t\t\t\t\t\t<div class=\"form-check\">\n\n\t\t\t\t\t\t\t\t\t<input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"checkEspaldaBaja3P5\">\n\t\t\t\t\t\t\t\t\t<label class=\"form-check-label\" for=\"defaultCheck1\">\n\n\n\t\t\t\t\t\t\t\t\t\tSciatic nerve R\/L\n\n\n\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"espaldaOtroP5\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n<h4>\n\n\t\t\t\t\t\t\tChest\n\n\t\t\t\t\t\t<\/h4>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tChest pain\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorPechoP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tRib pain\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorCostillasP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tPersistent cough\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"tosContinuaP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tShortness of breath\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"respiracionCortaP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tChest pain \/ pressure\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorPresionPechoP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tCough with phlegm\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"tosFlemaP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tHard to breath\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"resollarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tTrouble breathing at night\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"problemasRespirarNocheP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tPhlegm color\n\n\t\t\t\t\t\t\t<\/label>\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"flemaColorTextoP5\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"pechoOtrosP5\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n<h4>\n\n\t\t\t\t\t\t\tHips\n\n\t\t\t\t\t\t<\/h4>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tHip pain\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorCaderaP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"colorCaderaLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">R<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">L<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">both<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tpain in buttock\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorPompisP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dolorPompisLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tJoint transplant\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"transplanteArticulacionP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"transplanteArticulacionLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tSciatic pain\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorCiaticoP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dolorCiaticoLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tNumbness in the hip \/ buttock\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<select id=\"entumecimientoCaderaPompisP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"entumecimientoCaderaPompisLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tStabbing pain\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorPunzanteP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dolorPunzanteLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"caderaOtrosP5\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n<h4>\n\n\t\t\t\t\t\t\tLegs and knees\n\n\t\t\t\t\t\t<\/h4>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tPain in upper leg R\/L\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorMusloP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dolorMusloLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tCalf pain\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorPiernaP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dolorPiernaLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tKnee pain\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorRodillaP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dolorRodillaLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tNumbness \/ Tingling\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<select id=\"entumecimientoHormigueoP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"entumecimientoHormigueoLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tMuscle cramp R\/L\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"calambreP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"calambreLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tLeg cramp\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"calambrePiernaP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"calambrePiernaLugarP5\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"piernasRodillasOtroP5\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n<h4>\n\n\t\t\t\t\t\t\tAnkles, feet and toes\n\n\t\t\t\t\t\t<\/h4>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tAnkle pain\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorTobilloP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dolorTobilloLugarP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">R<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">L<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">both<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tFoot pain\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorPieP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dolorPieLugarP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tToe pain R\/L\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorDedosP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dolorDedosLugarP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tNumbness at ankles\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<select id=\"entumecimientoTobillosP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"entumecimientoTobillosLugarP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tNumbness in foot\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<select id=\"entumecimientoPiesP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"entumecimientoPiesLugarP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tNumbness in toes R\/L\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<select id=\"entumecimientoDedosP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"entumecimientoDedosLugarP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tBoth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tSwollen ankle\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"tobilloHinchadoP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"tobilloHinchadoLugarP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tSwollen feet\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"piesHinchadosP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"piesHinchadosLugarP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tSwollen toes R\/L\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dedosHinchadosP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dedosHinchadosLugarP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tSprained ankle R\/L\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"torceduraTobilloP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"torceduraTobilloLugarP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tHot \/ cold feet\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"piesCalientesFriosP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"piesCalientesFriosLugarP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tboth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-1 col-form-label\">\n\n\t\t\t\t\t\t\t\tHot\/cold toes\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dedosCalientesFriosP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t\t\t<select id=\"dedosCalientesFriosLugarP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tR\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tL\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tBoth\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"otroTobillosPiesP6\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t\n\n\n                        <button type=\"button\" class=\"site-btn\" style=\"float: right;\" onclick=\"siguientePagina(8)\">Next page<\/button>\n                        <button type=\"button\" class=\"site-btn\" style=\"float: left;\" onclick=\"anteriorPagina(8)\">Previous page<\/button>\n\n\t\t\t\t\t\n\t\t\t\t\t<\/form>\n\n\t\t\t\t\t<form class=\"contact-form\" id=\"pagina9\" action=\"#\" style=\"display: none;\">\n<h4 style=\"color: #396B39;\">\n\t\t\t\t\t\t\tExamination of internal organs\n\t\t\t\t\t\t<\/h4>\n\t\t\t\t\t\t<br>\n<h4>\n\n\t\t\t\t\t\t\tLungs, Heart\n\n\t\t\t\t\t\t<\/h4>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tHard to breath\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dificultadRespirar\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tChest pain\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorPechoP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tAnkle swelling\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"inflamacionTobillosP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tPersistent cough\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"tosPersistente\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tHigh blood pressure\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"presionAltaP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tVaricose veins\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"venasVaricosasP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tCoughing phlegm\n\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"flemasToserP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tLow blood pressure\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"presionBajaP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tPacemaker\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"marcapasoP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tCoughing blood\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"sangreToserP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tTachycardia\/irregular beat\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"taquicardiaLatidoP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tAngioplasty\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"angioplastiaP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"pulmonesCorazonOtroP6\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<h4>\n\n\t\t\t\t\t\t\tLiver and gallbladder\n\n\t\t\t\t\t\t<\/h4>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-1 col-form-label\"> Hepatitis<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-1\">\n\n\t\t\t\t\t\t\t\t<select id=\"hepatitisP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"hepatitisTipoP6\" placeholder=\"Type\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tHigh cholesterol\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"colesterolAltoP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tGallstones\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"calculoBiliarP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tSclerosis\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"esclerosisP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\thigh triglycerides\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"trigleceridoAltoP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tGallblader surgery\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"cirugiaVesiculaP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"higadoVesiculaOtroP6\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<h4>\n\n\t\t\t\t\t\t\tKidney and urinary bladder\n\n\t\t\t\t\t\t<\/h4>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tKidney infections\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"infeccionRinonP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tFrequent bladder infections\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"infeccionVejigaP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tPain when urinating\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorOrinarP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tKidney stones\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"piedrasRinonP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tIncontinence\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"incontinenciaP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tFrequent urination\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"orinaFrecuenteP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Water retention <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"retencionAguaP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tBlood in urine\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"sangreOrinaP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tExcessive thirst\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"sedExcesivaP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tBed wetting\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"orinaCamaP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tBad odor in urine\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"malOlorOrinaP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tHard to urinate\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dificultadOrinarP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tKidney disorder\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"desordenRinonP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tBladder disorder\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"desordenVejigaP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tHemodialysis program\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"HemoP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tLoss of urine w\/ cough\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"orinaToserP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tDifficult start\/stop urination\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"stopUrineP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"kidneyOtroP6\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\t\t\t\t\t\t<h4>\n\n\t\t\t\t\t\t\tStomach, digestion and appetite\n\n\t\t\t\t\t\t<\/h4>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tHeartburn\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"acidezP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tNausea \/ Vomiting\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"nauseaVomitoP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tExcessive appetite\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"apetitoExcesivoP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tStomach pain\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorEstomagoP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tStomach cramps\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"retorcijonesEstomagoP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tPoor appetite\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"malApetitoP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Gastritis <\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"gastritisP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tAbdominal bloating\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"inflamacionAbdominalP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tAppetite changes\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"apetitoCambianteP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tBad breath\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"malAlientoP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tBitter\/sour taste in mouth\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"saborAmargoP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tFood allergies\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"alergiaComidasP6\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"estomagoOtroP6\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n<h4>\n\n\t\t\t\t\t\t\tSmall intestine, large intestine and rectum\n\n\t\t\t\t\t\t<\/h4>\n\t\t\t\t\t\t<br>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tIndigestion\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"indigestionP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tConstipation\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"estrenimientoP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tHemorrhoids\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"hemorroidesP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tParasites\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"parasitosP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tDiarrhea\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"diarreaP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tPainful evacuation\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"evacuacionDolorosaP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tDiverculitis\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"diverculitisP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tColitis\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"colitisP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tBloody stools\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"excrementoSangrientoP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tAbdominal pain\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"dolorAbdominalP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tIrritable bowel\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"irritableP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tMucus in the stool\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"mocoExcrementoP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tLower bowel gas\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"gasIntestinoBajoP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tStool has foul odor\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"excrementoOlorP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tBlack stool\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"blackStoolP7\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"intestinoOtroP7\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"row\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-5\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"colorExcrementoP7\" placeholder=\"What color is your stool\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-5\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"vecesEvacuaP7\" placeholder=\"How often do you have a bowel movement?\">\n\t\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n<h4>\n\n\t\t\t\t\t\t\tSkin and sweating\n\n\t\t\t\t\t\t<\/h4>\n\t\t\t\t\t\t<br>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tDry\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"secaP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tAcne\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"acneP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tNight sweats\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"sudaNocheP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tItchy\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"comezonP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tPsoriasis\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"soriasisP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tExcessive sweating\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"sudorExcesivoP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tMoist\/clammy\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"humedoFrioP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tSkin rash\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"sarpullidoP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tRarely sweat\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"raraSudaP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tBurning\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"quemazonP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> Hives \/ eczema<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"urticariaEczemaP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tChanging moles\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"lunaresCambiantesP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tLumps \/ tumors \/ cysts\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"bolasTumoresQuistesP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">Shingles<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"herpesP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tDry scalp\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"cueroCabelludoP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tVaricose veins\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"venasVaricosasP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tBruises easily (black and blue)\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"moretesFacilesP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tHair loss\n\n\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"perdidaCabelloP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tFever \/ Chills\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"fiebreEscalofriosP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\">\n\n\t\t\t\t\t\t\t\tInflammation\n\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"inflamacinoP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<label for=\"enfermedadHigadoP3\" class=\"col-sm-2 col-form-label\"> Edema <\/label>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-2\">\n\n\t\t\t\t\t\t\t\t<select id=\"edemaP8\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">\n\n\t\t\t\t\t\t\t\t\t\t-\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">\n\n\t\t\t\t\t\t\t\t\t\tToday\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">\n\n\t\t\t\t\t\t\t\t\t\tPast\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">\n\n\t\t\t\t\t\t\t\t\t\tPast and Today\n\n\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t<\/select>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\t\t\t\t\t\t\t<div class=\"col-sm-12\">\n\t\t\t\t\t\t\t\t<br>\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"otroPielSudorP8\" placeholder=\"Other\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"border-top my-3\"><\/div>\n\n\n                        <button type=\"button\" class=\"site-btn\" style=\"float: right;\" onclick=\"siguientePagina(9)\">Next page<\/button>\n                        <button type=\"button\" class=\"site-btn\" style=\"float: left;\" onclick=\"anteriorPagina(9)\">Previous page<\/button>\n\n\t\t\t\t\t\n\t\t\t\t\t<\/form>\n\n\n\t\t\t\t<form class=\"contact-form\" id=\"pagina10\" action=\"#\" style=\"display: none;\">\n\n\t\t\t\t\t<h4 style=\"color: #396B39;\">REQUEST FOR ACUPUNCTURE TREATMENT<\/h4>\n\t\t\t\t\t<br>\n\n\t\t\t\t\t<p>I understand that treatment methods may include (but are not limited to) acupuncture, electrical stimulation, chiropractic, Tui Na (Chinese massage), Swedish massage, Chinese herbal medicine, and supplements, nutrition and lifestyle advice. This clinic uses sterile, (single use) disposable needles.<\/p>\n<p>I will notify the acupuncturist if I am or become pregnant; if there is any change in my health condition or medications or if I have any adverse reaction to the treatments.<\/p>\n<p>I understand all my records will be kept confidential and will not be disclosed without my written consent.<\/p>\n<p>My intention is to receive and complete the course of treatment for my current condition and for any future condition(s) for which I seek treatment.<\/p>\n\n\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\n\t\t\t\t\t\t<div class=\"col-sm-3\">\n\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"fechaP9\" placeholder=\"Date\">\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"col-sm-9\">\n\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"nombreFirmaP9\" placeholder=\"Patients Name\">\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\n\t\t\t\t\t\t<div class=\"col-sm-5\">\n\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"guardianesP9\" placeholder=\"Patients guardian or representative\">\n\t\t\t\t\t\t<\/div>\n\n\n\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\n\t\t\t\t\t\t<div class=\"col-sm-5\">\n\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"relacionP9\" placeholder=\"Relationship\">\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"col-sm-1\">\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"col-sm-6\">\n\t\t\t\t\t\t\t<label for=\"diabetesP3\" class=\"col-sm-2 col-form-label\"> _______________________________________ <\/label>\n\t\t\t\t\t\t\t<p>&emsp;Richard Smithee<\/p>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<br>\n\t\t\t\t\t<button type=\"button\" class=\"site-btn\" style=\"float: right;\" onclick=\"siguientePagina(10)\">Next page<\/button>\n\t\t\t\t\t<button type=\"button\" class=\"site-btn\" style=\"float: left;\" onclick=\"anteriorPagina(10)\">Previous page<\/button>\n\n\t\t\t\t<\/form>\n\n\t\t\t\t\t<form class=\"contact-form\" id=\"pagina11\" style=\"display: none;\" action=\"#\">\n\n\t\t\t\t\t\t<p>You have finished the ?Patient Information? form for Passport To Health. Below please enter your name, your email address, and then select the button where the form is to be sent. To the Clinic<\/p>\n\n\n\t\t\t\t\t\t<div class=\"form-group row align-items-center\">\n\n\n\t\t\t\t\t\t\t<div class=\"col-sm-6\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"nombreP10\" placeholder=\"Full name\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"col-sm-6\">\n\t\t\t\t\t\t\t\t<input type=\"text\" class=\"form-control\" id=\"emailP10\" placeholder=\"Your Email\">\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<!-- \t<p><strong>Note:<\/strong> Once you have sent the document please allow sufficient time for the data to be transmitted (do not refresh the page). It takes time to transmit this amount of data. Once the data has been sent you will receive ?Sent Successfully, sorry for the inconvenience, thank you!<\/p>-->\n\n\t\t\t\t\t\t<button type=\"button\" class=\"site-btn\" style=\"float: left;\" onclick=\"anteriorPagina(11)\">Previous page<\/button>\n\t\t\t\t\t\t<button type=\"button\" onclick=\"save()\" id=\"btnSave\" class=\"site-btn\" style=\"background-color: black; float: right; margin-left: 10px;\">Send to the clinic!<\/button>\n\t\t\t\t\t\n\t\t\t\t\t<\/form>\n\t\t\t\t\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n    <\/div>\n<\/section>\n<\/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\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-59377","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/pmitsdev.com\/pasaporte2\/wp-json\/wp\/v2\/pages\/59377","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pmitsdev.com\/pasaporte2\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/pmitsdev.com\/pasaporte2\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/pmitsdev.com\/pasaporte2\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/pmitsdev.com\/pasaporte2\/wp-json\/wp\/v2\/comments?post=59377"}],"version-history":[{"count":10,"href":"https:\/\/pmitsdev.com\/pasaporte2\/wp-json\/wp\/v2\/pages\/59377\/revisions"}],"predecessor-version":[{"id":60023,"href":"https:\/\/pmitsdev.com\/pasaporte2\/wp-json\/wp\/v2\/pages\/59377\/revisions\/60023"}],"wp:attachment":[{"href":"https:\/\/pmitsdev.com\/pasaporte2\/wp-json\/wp\/v2\/media?parent=59377"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}