{"id":3339,"date":"2021-12-17T14:21:51","date_gmt":"2021-12-17T06:21:51","guid":{"rendered":"https:\/\/neuroaid.com\/consulta\/"},"modified":"2026-08-14T10:55:59","modified_gmt":"2026-08-14T02:55:59","slug":"consulta","status":"publish","type":"page","link":"https:\/\/neuroaid.com\/es\/consulta\/","title":{"rendered":"Consulta"},"content":{"rendered":"[vc_row type=\u00bbfull_width_background\u00bb full_screen_row_position=\u00bbmiddle\u00bb column_margin=\u00bbdefault\u00bb column_direction=\u00bbdefault\u00bb column_direction_tablet=\u00bbdefault\u00bb column_direction_phone=\u00bbdefault\u00bb scene_position=\u00bbcenter\u00bb text_color=\u00bbdark\u00bb text_align=\u00bbleft\u00bb row_border_radius=\u00bbnone\u00bb row_border_radius_applies=\u00bbbg\u00bb row_position_desktop=\u00bbdefault\u00bb row_position_tablet=\u00bbinherit\u00bb row_position_phone=\u00bbinherit\u00bb overflow=\u00bbvisible\u00bb advanced_gradient_angle=\u00bb0&#8243; overlay_strength=\u00bb0.3&#8243; gradient_direction=\u00bbleft_to_right\u00bb shape_divider_position=\u00bbbottom\u00bb bg_image_animation=\u00bbnone\u00bb gradient_type=\u00bbdefault\u00bb shape_type=\u00bb\u00bb][vc_column column_padding=\u00bbno-extra-padding\u00bb column_padding_tablet=\u00bbinherit\u00bb column_padding_phone=\u00bbinherit\u00bb column_padding_position=\u00bball\u00bb flex_gap_desktop=\u00bb10px\u00bb column_element_direction_desktop=\u00bbdefault\u00bb column_element_spacing=\u00bbdefault\u00bb desktop_text_alignment=\u00bbdefault\u00bb tablet_text_alignment=\u00bbdefault\u00bb phone_text_alignment=\u00bbdefault\u00bb background_color_opacity=\u00bb1&#8243; background_hover_color_opacity=\u00bb1&#8243; column_backdrop_filter=\u00bbnone\u00bb column_shadow=\u00bbnone\u00bb column_border_radius=\u00bbnone\u00bb column_link_target=\u00bb_self\u00bb column_position=\u00bbdefault\u00bb gradient_direction=\u00bbleft_to_right\u00bb overlay_strength=\u00bb0.3&#8243; width=\u00bb1\/1&#8243; tablet_width_inherit=\u00bbdefault\u00bb animation_type=\u00bbdefault\u00bb bg_image_animation=\u00bbnone\u00bb border_type=\u00bbsimple\u00bb column_border_width=\u00bbnone\u00bb column_border_style=\u00bbsolid\u00bb]\n\t\t\t\t<p class=\"rs-p-wp-fix\"><\/p>\n\t\t\t\t<sr7-module data-alias=\"patients-testimonials-1\" data-id=\"253\" id=\"SR7_253_1\" class=\"rs-ov-hidden\" data-version=\"6.7.56\">\n\t\t\t\t\t<sr7-adjuster><\/sr7-adjuster>\n\t\t\t\t\t<sr7-content>\n\t\t\t\t\t\t<sr7-slide id=\"SR7_253_1-72\" data-key=\"72\">\n\t\t\t\t\t\t\t<sr7-bg id=\"SR7_253_1-72-39\" class=\"sr7-layer\"><noscript><img decoding=\"async\" src=\"https:\/\/neuroaid.com\/v2\/wp-content\/uploads\/senior-woman-helping-senior-man-to-use-computer-2021-09-02-07-09-04-utc-min-scaled.jpg\" alt=\"\" title=\"senior-woman-helping-senior-man-to-use-computer-2021-09-02-07-09-04-utc-min\"><\/noscript><\/sr7-bg>\n\t\t\t\t\t\t\t<a id=\"SR7_253_1-72-1\" class=\"sr7-layer\" href=\"https:\/\/neuroaid.com\/es\" target=\"_self\">Inicio<\/a>\n\t\t\t\t\t\t\t<sr7-txt id=\"SR7_253_1-72-2\" class=\"sr7-layer\">Acerca \u25be<\/sr7-txt>\n\t\t\t\t\t\t\t<a id=\"SR7_253_1-72-3\" class=\"sr7-layer\" href=\"https:\/\/neuroaid.com\/es\/biblioteca\/\" target=\"_self\">Biblioteca<\/a>\n\t\t\t\t\t\t\t<a id=\"SR7_253_1-72-4\" class=\"sr7-layer\" href=\"https:\/\/neuroaid.com\/es\/contacto\/\" target=\"_self\">contacto<\/a>\n\t\t\t\t\t\t\t<a id=\"SR7_253_1-72-6\" class=\"sr7-layer\" href=\"https:\/\/buy.neuroaid.com\/es\" target=\"_self\">pedido<\/a>\n\t\t\t\t\t\t\t<a id=\"SR7_253_1-72-7\" class=\"sr7-layer\" href=\"https:\/\/neuroaid.com\/es\/acerca-de-neuroaid\/\" target=\"_self\">Acerca de NeuroAiD \u25b8<\/a>\n\t\t\t\t\t\t\t<a id=\"SR7_253_1-72-9\" class=\"sr7-layer\" href=\"https:\/\/neuroaid.com\/es\/estudios-clinicos\/\" target=\"_self\">estudios cl\u00ednicos \u25b8<\/a>\n\t\t\t\t\t\t\t<a id=\"SR7_253_1-72-10\" class=\"sr7-layer\" href=\"https:\/\/neuroaid.com\/es\/perfil-de-seguridad\/\" target=\"_self\">perfil de seguridad \u25b8<\/a>\n\t\t\t\t\t\t\t<a id=\"SR7_253_1-72-11\" class=\"sr7-layer\" href=\"https:\/\/neuroaid.com\/es\/profesionales-medicos\/\" target=\"_self\">Profesional m\u00e9dico<br \/>\n<\/a>\n\t\t\t\t\t\t\t<a id=\"SR7_253_1-72-12\" class=\"sr7-layer\" href=\"https:\/\/neuroaid.com\/es\/composicion-y-dosis\/\" target=\"_self\">composici\u00f3n y dosificaci\u00f3n \u25b8<\/a>\n\t\t\t\t\t\t\t<sr7-txt id=\"SR7_253_1-72-26\" class=\"sr7-layer\">Acerca<\/sr7-txt>\n\t\t\t\t\t\t\t<sr7-txt id=\"SR7_253_1-72-27\" class=\"sr7-layer\"><br \/>\nNeuroAiD es un tratamiento oral que ayuda a los pacientes de accidentes cerebrovasculares y lesiones cerebrales traum\u00e1ticas que sufren d\u00e9ficits establecidos a recuperar su independencia funcional adem\u00e1s de terapias de rehabilitaci\u00f3n y ejercicios.<\/sr7-txt>\n\t\t\t\t\t\t\t<sr7-txt id=\"SR7_253_1-72-38\" class=\"sr7-layer\">Consulta<\/sr7-txt>\n\t\t\t\t\t\t<\/sr7-slide>\n\t\t\t\t\t\t<sr7-slide id=\"SR7_253_1-158\" data-key=\"158\">\n\t\t\t\t\t\t<\/sr7-slide>\n\t\t\t\t\t<\/sr7-content>\n\t\t\t\t\t<image_lists style=\"display:none\">\n\t\t\t\t\t\t<img data-src=\"\/\/neuroaid.com\/v2\/wp-content\/uploads\/NAII_3-e1613530758649.png\" data-libid=\"55\" data-lib=\"medialibrary\" title=\"NAII_3\" width=\"0\" height=\"0\" data-dbsrc=\"Ly9uZXVyb2FpZC5jb20vdjIvd3AtY29udGVudC91cGxvYWRzL05BSUlfMy1lMTYxMzUzMDc1ODY0OS5wbmc=\"\/>\n\t\t\t\t\t\t<img data-src=\"\/\/neuroaid.com\/v2\/wp-content\/uploads\/senior-woman-helping-senior-man-to-use-computer-2021-09-02-07-09-04-utc-min-scaled.jpg\" data-libid=\"3272\" data-lib=\"medialibrary\" title=\"senior-woman-helping-senior-man-to-use-computer-2021-09-02-07-09-04-utc-min\" width=\"0\" height=\"0\" 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].fn();\n\t\t\t\t<\/script>\n[\/vc_column][\/vc_row][vc_row type=\u00bbin_container\u00bb full_screen_row_position=\u00bbmiddle\u00bb column_margin=\u00bbdefault\u00bb column_direction=\u00bbdefault\u00bb column_direction_tablet=\u00bbdefault\u00bb column_direction_phone=\u00bbdefault\u00bb scene_position=\u00bbcenter\u00bb top_padding=\u00bb50&#8243; text_color=\u00bbdark\u00bb text_align=\u00bbleft\u00bb row_border_radius=\u00bbnone\u00bb row_border_radius_applies=\u00bbbg\u00bb row_position_desktop=\u00bbdefault\u00bb row_position_tablet=\u00bbinherit\u00bb row_position_phone=\u00bbinherit\u00bb overflow=\u00bbvisible\u00bb advanced_gradient_angle=\u00bb0&#8243; overlay_strength=\u00bb0.3&#8243; gradient_direction=\u00bbleft_to_right\u00bb shape_divider_position=\u00bbbottom\u00bb bg_image_animation=\u00bbnone\u00bb gradient_type=\u00bbdefault\u00bb shape_type=\u00bb\u00bb][vc_column column_padding=\u00bbno-extra-padding\u00bb column_padding_tablet=\u00bbinherit\u00bb 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class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; se\u00f1ala los campos obligatorios<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_19'  action='\/es\/wp-json\/wp\/v2\/pages\/3339#gf_19' data-formid='19' novalidate>\n        <div id='gf_progressbar_wrapper_19' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Paso <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>7<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_custom' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_custom percentbar_14' style='width:14%; color:#fff; background-color:#19388A;'><span>14%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_19_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_19' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_19_126\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_126'><span class='gform-field-label__text'>Name<\/span><\/label><div class='ginput_container'><input name='input_126' id='input_19_126' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_19_126'>Este campo es un campo de validaci\u00f3n y debe quedar sin cambios.<\/div><\/div><div id=\"field_19_24\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_19_24'>Cu\u00e9ntenos sobre el paciente y nos pondremos en contacto.<\/div><\/div><fieldset id=\"field_19_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full condition-cards gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Seleccione una condici\u00f3n<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_19_56'>\n\t\t\t<div class='gchoice gchoice_19_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Stroke'  id='choice_19_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_19_56_0' id='label_19_56_0' class='gform-field-label gform-field-label--type-inline'><span class=\"condition-content\">     <span class=\"condition-left\">         <i class=\"fa-solid fa-brain\"><\/i>         <span>Accidente cerebrovascular (ACV)<\/span>     <\/span>      <i class=\"fa-solid fa-angle-right\"><\/i> <\/span><\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_19_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Alzheimer&#039;s disease'  id='choice_19_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_19_56_1' id='label_19_56_1' class='gform-field-label gform-field-label--type-inline'><span class=\"condition-content\">     <span class=\"condition-left\">         <i class=\"fa-solid fa-brain\"><\/i>         <span>Enfermedad de Alzheimer<\/span>     <\/span>      <i class=\"fa-solid fa-angle-right\"><\/i> <\/span><\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_19_56_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Traumatic brain injury'  id='choice_19_56_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_19_56_2' id='label_19_56_2' class='gform-field-label gform-field-label--type-inline'><span class=\"condition-content\">     <span class=\"condition-left\">         <i class=\"fa-solid fa-brain\"><\/i>         <span>Traumatismo craneoencef\u00e1lico<\/span>     <\/span>      <i class=\"fa-solid fa-angle-right\"><\/i> <\/span><\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_19_53' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Continuar<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_19_2' class='gform_page nextprevbtn' data-js='page-field-id-53' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_19_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_19_66\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informaci\u00f3n del paciente<\/h3><\/div><div id=\"field_19_49\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><em style=\"font-size: 12px; font-weight: bold; color: #242c74; text-align: left;\">(Tenga en cuenta que los campos marcados con * son obligatorios.)<\/em><\/div><div id=\"field_19_64\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_64'><span class='gform-field-label__text'>\u00bfPor qui\u00e9n realiza la consulta?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_64' id='input_19_64' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione una opci\u00f3n<\/option><option value='Myself' >Para m\u00ed<\/option><option value='My Spouse \/ Partner' >Mi c\u00f3nyuge o pareja<\/option><option value='My Parent' >Mi padre o madre<\/option><option value='Another family member' >Otro familiar<\/option><option value='A friend' >Un amigo o amiga<\/option><option value='Someone else' >Otra persona<\/option><\/select><\/div><\/div><div id=\"field_19_61\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_61'><span class='gform-field-label__text'>Edad<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_61' id='input_19_61' type='number' step='any'   value='' class='large'    placeholder='Introduzca la edad' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_19_62' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Anterior<\/button> <button type='button' id='gform_next_button_19_62' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Continuar<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_19_3' class='gform_page nextprevbtn' data-js='page-field-id-62' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_19_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_19_67\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Detalles de la afecci\u00f3n (ictus)<\/h3><\/div><div id=\"field_19_91\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><em style=\"font-size: 12px; font-weight: bold; color: #242c74; text-align: left;\">(Tenga en cuenta que los campos marcados con * son obligatorios.)<\/em><\/div><div id=\"field_19_125\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_125'><span class='gform-field-label__text'>Tiempo transcurrido desde el diagn\u00f3stico<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_125' id='input_19_125' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione una opci\u00f3n<\/option><option value='Less than 4 weeks' >Menos de 4 semanas<\/option><option value='1\u20133 months' >De 1 a 3 meses<\/option><option value='More than 3 months' >M\u00e1s de 3 meses<\/option><\/select><\/div><\/div><fieldset id=\"field_19_69\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half pill-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Tipo de ictus<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_19_69'>\n\t\t\t<div class='gchoice gchoice_19_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Ischemic'  id='choice_19_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_19_69_0' id='label_19_69_0' class='gform-field-label gform-field-label--type-inline'>Isqu\u00e9mico<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_19_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Hemorrhagic'  id='choice_19_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_19_69_1' id='label_19_69_1' class='gform-field-label gform-field-label--type-inline'>Hemorr\u00e1gico<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_19_69_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Not sure'  id='choice_19_69_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_19_69_2' id='label_19_69_2' class='gform-field-label gform-field-label--type-inline'>No estoy seguro\/a<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_19_71\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Principales funciones afectadas<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_19_71'>(Seleccione todas las opciones que correspondan)<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_19_71'><div class='gchoice gchoice_19_71_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.1' type='checkbox'  value='Motor \/ Movement'  id='choice_19_71_1'   aria-describedby=\"gfield_description_19_71\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_19_71_1' id='label_19_71_1' class='gform-field-label gform-field-label--type-inline'>Motricidad \/ movimiento<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_71_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.2' type='checkbox'  value='Sensory'  id='choice_19_71_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_71_2' id='label_19_71_2' class='gform-field-label gform-field-label--type-inline'>Sensibilidad<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_71_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.3' type='checkbox'  value='Vision'  id='choice_19_71_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_71_3' id='label_19_71_3' class='gform-field-label gform-field-label--type-inline'>Visi\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_71_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.4' type='checkbox'  value='Cognition \/ Memory'  id='choice_19_71_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_71_4' id='label_19_71_4' class='gform-field-label gform-field-label--type-inline'>Cognici\u00f3n \/ memoria<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_71_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.5' type='checkbox'  value='Speech'  id='choice_19_71_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_71_5' id='label_19_71_5' class='gform-field-label gform-field-label--type-inline'>Habla<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_71_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.6' type='checkbox'  value='Swallowing'  id='choice_19_71_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_71_6' id='label_19_71_6' class='gform-field-label gform-field-label--type-inline'>Degluci\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_71_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.7' type='checkbox'  value='Others'  id='choice_19_71_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_71_7' id='label_19_71_7' class='gform-field-label gform-field-label--type-inline'>Otros<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_111\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_111'><span class='gform-field-label__text'>Si ha seleccionado Otros, especifique:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_111' id='input_19_111' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_19_10\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_10'><span class='gform-field-label__text'>Nivel actual de autonom\u00eda<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_10' id='input_19_10' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione una opci\u00f3n<\/option><option value='Between 0% and 20%' >Entre el 0 % y el 20 % (no puede realizar ninguna actividad diaria por s\u00ed mismo\/a)<\/option><option value='Between 20% and 50%' >Entre el 20 % y el 50 %<\/option><option value='Between 50% and 80%' >Entre el 50 % y el 80 %<\/option><option value='More than 80%' >M\u00e1s del 80 % (puede realizar la mayor\u00eda de las actividades diarias por s\u00ed mismo\/a)<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_19_75' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Anterior<\/button> <button type='button' id='gform_next_button_19_75' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Continuar<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_19_4' class='gform_page' data-js='page-field-id-75' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_19_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_19_74\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Detalles de la afecci\u00f3n (enfermedad de Alzheimer)<\/h3><\/div><div id=\"field_19_92\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><em style=\"font-size: 12px; font-weight: bold; color: #242c74; text-align: left;\">(Tenga en cuenta que los campos marcados con * son obligatorios.)<\/em><\/div><div id=\"field_19_122\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_122'><span class='gform-field-label__text'>Tiempo transcurrido desde el diagn\u00f3stico<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_122' id='input_19_122' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione una opci\u00f3n<\/option><option value='Less than 4 weeks' >Menos de 4 semanas<\/option><option value='1\u20133 months' >De 1 a 3 meses<\/option><option value='More than 3 months' >M\u00e1s de 3 meses<\/option><\/select><\/div><\/div><div id=\"field_19_112\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_112'><span class='gform-field-label__text'>Diagn\u00f3stico realizado por<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_112' id='input_19_112' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione una opci\u00f3n<\/option><option value='General \/ Family physician' >M\u00e9dico general o de familia<\/option><option value='Geriatrican' >Geriatra<\/option><option value='Neurologist' >Neur\u00f3logo<\/option><option value='Psychiatrist' >Psiquiatra<\/option><option value='Others' >Otro profesional<\/option><\/select><\/div><\/div><div id=\"field_19_113\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_113'><span class='gform-field-label__text'>Si ha seleccionado Otros, especifique:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_19_113' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_19_78\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Principales s\u00edntomas o dificultades (enfermedad de Alzheimer)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_19_78'>(Seleccione todas las opciones que correspondan)<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_19_78'><div class='gchoice gchoice_19_78_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.1' type='checkbox'  value='Cognition \/ Memory'  id='choice_19_78_1'   aria-describedby=\"gfield_description_19_78\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_19_78_1' id='label_19_78_1' class='gform-field-label gform-field-label--type-inline'>Cognici\u00f3n \/ memoria<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_78_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.2' type='checkbox'  value='Daily functioning'  id='choice_19_78_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_78_2' id='label_19_78_2' class='gform-field-label gform-field-label--type-inline'>Actividades de la vida diaria<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_78_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.3' type='checkbox'  value='Behavioural \/ Mood'  id='choice_19_78_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_78_3' id='label_19_78_3' class='gform-field-label gform-field-label--type-inline'>Comportamiento \/ estado de \u00e1nimo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_78_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.4' type='checkbox'  value='Communication \/ Language'  id='choice_19_78_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_78_4' id='label_19_78_4' class='gform-field-label gform-field-label--type-inline'>Comunicaci\u00f3n \/ lenguaje<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_78_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.5' type='checkbox'  value='Orientation \/ Navigation'  id='choice_19_78_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_78_5' id='label_19_78_5' class='gform-field-label gform-field-label--type-inline'>Orientaci\u00f3n \/ desplazamiento<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_78_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.6' type='checkbox'  value='Others'  id='choice_19_78_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_78_6' id='label_19_78_6' class='gform-field-label gform-field-label--type-inline'>Otros<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_99\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_99'><span class='gform-field-label__text'>Si ha seleccionado Otros, especifique:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_19_99' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_19_79\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_79'><span class='gform-field-label__text'>Nivel actual de autonom\u00eda<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_79' id='input_19_79' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione una opci\u00f3n<\/option><option value='Fully independent with personal cares and instrumental activities of daily living (iADLs)' >Totalmente independiente para el cuidado personal y las actividades instrumentales de la vida diaria (AIVD)<\/option><option value='Fully independent with personal cares but requires assistance with iADLs' >Totalmente independiente para el cuidado personal, pero necesita ayuda con las AIVD<\/option><option value='Requires assistance with both personal cares and iADLs)' >Necesita ayuda tanto con el cuidado personal como con las AIVD<\/option><\/select><\/div><\/div><fieldset id=\"field_19_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full pill-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfActualmente toma alg\u00fan medicamento para la enfermedad de Alzheimer?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_19_80'>\n\t\t\t<div class='gchoice gchoice_19_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Yes'  id='choice_19_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_19_80_0' id='label_19_80_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_19_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='No'  id='choice_19_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_19_80_1' id='label_19_80_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_19_82\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>En caso afirmativo, seleccione todas las opciones que correspondan:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_19_82'><div class='gchoice gchoice_19_82_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.1' type='checkbox'  value='Donepezil'  id='choice_19_82_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_82_1' id='label_19_82_1' class='gform-field-label gform-field-label--type-inline'>Donepezilo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_82_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.2' type='checkbox'  value='Rivastigmine'  id='choice_19_82_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_82_2' id='label_19_82_2' class='gform-field-label gform-field-label--type-inline'>Rivastigmina<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_82_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.3' type='checkbox'  value='Galantamine'  id='choice_19_82_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_82_3' id='label_19_82_3' class='gform-field-label gform-field-label--type-inline'>Galantamina<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_82_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.4' type='checkbox'  value='Memantine'  id='choice_19_82_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_82_4' id='label_19_82_4' class='gform-field-label gform-field-label--type-inline'>Memantina<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_82_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.5' type='checkbox'  value='Anti-amyloid monoclonal antibody'  id='choice_19_82_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_82_5' id='label_19_82_5' class='gform-field-label gform-field-label--type-inline'>Anticuerpo monoclonal antiamiloide<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_82_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.6' type='checkbox'  value='Others'  id='choice_19_82_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_82_6' id='label_19_82_6' class='gform-field-label gform-field-label--type-inline'>Otros<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_101\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_101'><span class='gform-field-label__text'>En caso afirmativo, seleccione todas las opciones que correspondan:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_19_101' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_19_83\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_83'><span class='gform-field-label__text'>\u00bfCu\u00e1nto tiempo lleva en tratamiento?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_19_83' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_19_72' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Anterior<\/button> <button type='button' id='gform_next_button_19_72' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Continuar<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_19_5' class='gform_page nextprevbtn' data-js='page-field-id-72' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_19_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_19_87\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Detalles de la afecci\u00f3n (traumatismo craneoencef\u00e1lico)<\/h3><\/div><div id=\"field_19_93\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><em style=\"font-size: 12px; font-weight: bold; color: #242c74; text-align: left;\">(Tenga en cuenta que los campos marcados con * son obligatorios.)<\/em><\/div><div id=\"field_19_123\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_123'><span class='gform-field-label__text'>Tiempo transcurrido desde el diagn\u00f3stico<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_123' id='input_19_123' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione una opci\u00f3n<\/option><option value='Less than 4 weeks' >Menos de 4 semanas<\/option><option value='1\u20133 months' >De 1 a 3 meses<\/option><option value='More than 3 months' >M\u00e1s de 3 meses<\/option><\/select><\/div><\/div><div id=\"field_19_86\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_86'><span class='gform-field-label__text'>Causa de la lesi\u00f3n<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_86' id='input_19_86' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione una opci\u00f3n<\/option><option value='Fall' >Ca\u00edda<\/option><option value='Motor vehicle accident' >Accidente de tr\u00e1fico<\/option><option value='Workplace injuries' >Accidente laboral<\/option><option value='Assault' >Agresi\u00f3n<\/option><option value='Sports injuries' >Lesi\u00f3n deportiva<\/option><option value='Others' >Otros<\/option><\/select><\/div><\/div><div id=\"field_19_104\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_104'><span class='gform-field-label__text'>Si ha seleccionado Otros, especifique:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_19_104' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_19_88\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_88'><span class='gform-field-label__text'>\u00bfQu\u00e9 profesional se encarg\u00f3 del seguimiento despu\u00e9s de la lesi\u00f3n?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_88' id='input_19_88' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione una opci\u00f3n<\/option><option value='Neurocirujano' >Neurocirujano<\/option><option value='Neur\u00f3logo' >Neur\u00f3logo<\/option><option value='M\u00e9dico rehabilitador' >M\u00e9dico rehabilitador<\/option><option value='M\u00e9dico general' >M\u00e9dico general<\/option><option value='Sin seguimiento m\u00e9dico' >Sin seguimiento m\u00e9dico<\/option><option value='Otros' >Otros<\/option><\/select><\/div><\/div><div id=\"field_19_107\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_107'><span class='gform-field-label__text'>Si ha seleccionado Otros, especifique:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_19_107' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_19_89\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_89'><span class='gform-field-label__text'>Nivel actual de autonom\u00eda<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_89' id='input_19_89' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione una opci\u00f3n<\/option><option value='Fully independent with personal cares and instrumental activities of daily living (iADLs)' >Totalmente independiente para el cuidado personal y las actividades instrumentales de la vida diaria (AIVD)<\/option><option value='Fully independent with personal cares but requires assistance with iADLs' >Totalmente independiente para el cuidado personal, pero necesita ayuda con las AIVD<\/option><option value='Requires assistance with both personal cares and iADLs' >Necesita ayuda tanto con el cuidado personal como con las AIVD<\/option><\/select><\/div><\/div><fieldset id=\"field_19_90\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col_vertical gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-columns\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Principales s\u00edntomas o dificultades (traumatismo craneoencef\u00e1lico)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_19_90'>(Seleccione todas las opciones que correspondan)<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_19_90'><div class='gchoice gchoice_19_90_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_90.1' type='checkbox'  value='Physical symptoms (e.g. headache, dizziness, photosensitivity, fatigue)'  id='choice_19_90_1'   aria-describedby=\"gfield_description_19_90\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_19_90_1' id='label_19_90_1' class='gform-field-label gform-field-label--type-inline'>S\u00edntomas f\u00edsicos (p. ej., dolor de cabeza, mareos, sensibilidad a la luz y fatiga)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_90_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_90.2' type='checkbox'  value='Cognitive symptoms (e.g. memory, attention, thinking)'  id='choice_19_90_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_90_2' id='label_19_90_2' class='gform-field-label gform-field-label--type-inline'>S\u00edntomas cognitivos (p. ej., problemas de memoria, atenci\u00f3n y pensamiento)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_90_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_90.3' type='checkbox'  value='Behavioural symptoms (e.g. mood, anxiety, irritability)'  id='choice_19_90_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_90_3' id='label_19_90_3' class='gform-field-label gform-field-label--type-inline'>S\u00edntomas conductuales (p. ej., cambios de \u00e1nimo, ansiedad e irritabilidad)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_19_90_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_90.4' type='checkbox'  value='Others'  id='choice_19_90_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_19_90_4' id='label_19_90_4' class='gform-field-label gform-field-label--type-inline'>Otros<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_108\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_108'><span class='gform-field-label__text'>Si ha seleccionado otros, especifique:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_108' id='input_19_108' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_19_84' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Anterior<\/button> <button type='button' id='gform_next_button_19_84' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Continuar<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_19_6' class='gform_page' data-js='page-field-id-84' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_19_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_19_95\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Detalles de la afecci\u00f3n (otras afecciones)<\/h3><\/div><div id=\"field_19_124\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_124'><span class='gform-field-label__text'>Tiempo transcurrido desde el diagn\u00f3stico<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_124' id='input_19_124' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione una opci\u00f3n<\/option><option value='Less than 4 weeks' >Menos de 4 semanas<\/option><option value='1\u20133 months' >De 1 a 3 meses<\/option><option value='More than 3 months' >M\u00e1s de 3 meses<\/option><\/select><\/div><\/div><div id=\"field_19_98\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_98'><span class='gform-field-label__text'>\u00bfQui\u00e9n realiz\u00f3 el diagn\u00f3stico?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_98' id='input_19_98' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione una opci\u00f3n<\/option><option value='General physician' >General physician<\/option><option value='Specialist' >Specialist<\/option><option value='Not formally diagnosed' >Not formally diagnosed<\/option><option value='Others' >Others<\/option><\/select><\/div><\/div><div id=\"field_19_110\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_110'><span class='gform-field-label__text'>Si ha seleccionado otros, especifique:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_19_110' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_19_96' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Anterior<\/button> <button type='button' id='gform_next_button_19_96' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Continuar<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_19_7' class='gform_page' data-js='page-field-id-96' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_19_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_19_73\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informaci\u00f3n de contacto<\/h3><\/div><div id=\"field_19_94\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><em style=\"font-size: 12px; font-weight: bold; color: #242c74; text-align: left;\">(Tenga en cuenta que los campos marcados con * son obligatorios.)<\/em><\/div><div id=\"field_19_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_17'><span class='gform-field-label__text'>Nombre<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_19_17' type='text' value='' class='large'    placeholder='Introduzca su nombre' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_19_116\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_116'><span class='gform-field-label__text'>Apellidos<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_116' id='input_19_116' type='text' value='' class='large'    placeholder='Introduzca sus apellidos' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_19_20\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_20'><span class='gform-field-label__text'>Correo electr\u00f3nico<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_20' id='input_19_20' type='email' value='' class='large'   placeholder='Introduzca su correo electr\u00f3nico' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_19_21\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_21'><span class='gform-field-label__text'>Pa\u00eds<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_19_21' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccione su pa\u00eds<\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brazil' >Brazil<\/option><option value='Brunei' >Brunei<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='East Timor' >East Timor<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='North Korea' >North Korea<\/option><option value='South Korea' >South Korea<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Norway' >Norway<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine' >Palestine<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia and Montenegro' >Serbia and Montenegro<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Sudan, South' >Sudan, South<\/option><option value='Suriname' >Suriname<\/option><option value='Swaziland' >Swaziland<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/div><div id=\"field_19_117\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_117'><span class='gform-field-label__text'>N\u00famero de contacto<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_117' id='input_19_117' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_19_23\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_23'><span class='gform-field-label__text'>Pregunta o comentario<\/span><\/label><div class='gfield_description' id='gfield_description_19_23'>(opcional)<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_19_23' class='textarea medium'  aria-describedby=\"gfield_description_19_23\"  placeholder='Escriba aqu\u00ed su pregunta o comentario'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_19_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full pill-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Me gustar\u00eda suscribirme al bolet\u00edn informativo de NeuroAiD.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_19_47'>\n\t\t\t<div class='gchoice gchoice_19_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Yes' checked='checked' id='choice_19_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_19_47_0' id='label_19_47_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_19_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='No'  id='choice_19_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_19_47_1' id='label_19_47_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_52\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_19_45\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_45' id='input_19_45' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='20\/08\/2026' \/><\/div><\/div><div id=\"field_19_46\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_46' id='input_19_46' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_19_50\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_19_50'><span class='gform-field-label__text'>CAPTCHA<\/span><\/label><div id='input_19_50' class='ginput_container ginput_recaptcha' data-sitekey='6LfFyRUUAAAAANt7PLSg8nLCqOFhcaC737Ggv4lb'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><fieldset id=\"field_19_118\" class=\"gfield gfield--type-time gfield--input-type-time field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Time<\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_19_118'>\n                            <input type='number' name='input_118[]' id='input_19_118_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_19_118_1'>Horas<\/label>\n                        <\/div>\n                        <div class=\"above hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_118[]' id='input_19_118_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_19_118_2'>Minutos<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time above gform-grid-col' >\n                                \n                                <select name='input_118[]' id='input_19_118_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select>\n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_19_118_3'>AM\/PM<\/label>\n                           <\/div>\n                    <\/div><\/fieldset><fieldset id=\"field_19_120\" class=\"gfield gfield--type-list gfield--input-type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>List<\/span><\/legend><div class='ginput_container ginput_container_list ginput_list '><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_120_cell1 gform-grid-col' ><input aria-invalid='false'   aria-label='List, Fila 1' data-aria-label-template='List, Fila {0}' type='text' name='input_120[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 0)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Eliminar fila {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><button type='submit' id='gform_previous_button_19' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Anterior<\/button> <button type='submit' id='gform_submit_button_19' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Enviar<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_19' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_19' id='gform_theme_19' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_19' id='gform_style_settings_19' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_19' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='19' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='03UeGwFxa\/irQOvD8Bo9764IiQXk04itisr\/KX1+vHUB+tn7UU3nsPCNM+9jav16Qibx9ca5O2kwy4pROoL+5GQ\/o3Df6lKHiF\/CPm3ZyXW\/XKE=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_19' 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MLC601 y MLC901 son 2 formulaciones patentadas diferentes cuya equivalencia farmacol\u00f3gica se ha demostrado y que se denominan NeuroAiD en esta p\u00e1gina web.<\/em><\/span>[\/vc_column_text][\/vc_column][\/vc_row][vc_row type=\u00bbin_container\u00bb full_screen_row_position=\u00bbmiddle\u00bb column_margin=\u00bbdefault\u00bb column_direction=\u00bbdefault\u00bb column_direction_tablet=\u00bbdefault\u00bb column_direction_phone=\u00bbcolumn_reverse\u00bb bg_color=\u00bb#19388a\u00bb scene_position=\u00bbcenter\u00bb top_padding=\u00bb5%\u00bb bottom_padding=\u00bb30&#8243; text_color=\u00bbdark\u00bb text_align=\u00bbleft\u00bb row_border_radius=\u00bbnone\u00bb row_border_radius_applies=\u00bbbg\u00bb row_position_desktop=\u00bbdefault\u00bb row_position_tablet=\u00bbinherit\u00bb row_position_phone=\u00bbinherit\u00bb overflow=\u00bbvisible\u00bb overlay_strength=\u00bb0.3&#8243; gradient_direction=\u00bbleft_to_right\u00bb enable_shape_divider=\u00bbtrue\u00bb shape_divider_color=\u00bb#ffffff\u00bb shape_divider_position=\u00bbtop\u00bb shape_divider_height=\u00bb80&#8243; bg_image_animation=\u00bbnone\u00bb shape_type=\u00bbcurve\u00bb gradient_type=\u00bbdefault\u00bb][vc_column column_padding=\u00bbno-extra-padding\u00bb column_padding_tablet=\u00bbinherit\u00bb column_padding_phone=\u00bbinherit\u00bb column_padding_position=\u00bball\u00bb top_margin=\u00bb10%\u00bb top_margin_tablet=\u00bb15%\u00bb top_margin_phone=\u00bb5%\u00bb flex_gap_desktop=\u00bb10px\u00bb column_element_direction_desktop=\u00bbdefault\u00bb column_element_spacing=\u00bbdefault\u00bb desktop_text_alignment=\u00bbdefault\u00bb tablet_text_alignment=\u00bbdefault\u00bb phone_text_alignment=\u00bbdefault\u00bb background_color_opacity=\u00bb1&#8243; background_hover_color_opacity=\u00bb1&#8243; column_backdrop_filter=\u00bbnone\u00bb column_shadow=\u00bbnone\u00bb column_border_radius=\u00bbnone\u00bb column_link_target=\u00bb_self\u00bb column_position=\u00bbdefault\u00bb gradient_direction=\u00bbleft_to_right\u00bb overlay_strength=\u00bb0.3&#8243; width=\u00bb2\/3&#8243; tablet_width_inherit=\u00bbsmall_desktop\u00bb animation_type=\u00bbdefault\u00bb bg_image_animation=\u00bbnone\u00bb border_type=\u00bbsimple\u00bb column_border_width=\u00bbnone\u00bb column_border_style=\u00bbsolid\u00bb column_padding_type=\u00bbdefault\u00bb gradient_type=\u00bbdefault\u00bb][vc_column_text css_animation=\u00bbbounceIn\u00bb css=\u00bb\u00bb text_direction=\u00bbdefault\u00bb]\n<h3><span style=\"color: #ffffff;\">Averig\u00fce si NeuroAiD es adecuado para su caso.<\/span><\/h3>\n<h4 style=\"text-align: left;\"><span style=\"color: #ffffff;\">Para enviar sus preguntas a nuestro equipo de Atenci\u00f3n al paciente, haga clic en el cuadro siguiente. 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