{"id":11,"date":"2026-05-28T20:53:57","date_gmt":"2026-05-28T20:53:57","guid":{"rendered":"https:\/\/www.ameci.cl\/declaracion-salud\/?page_id=11"},"modified":"2026-06-01T17:08:30","modified_gmt":"2026-06-01T17:08:30","slug":"declaracion-de-salud","status":"publish","type":"page","link":"https:\/\/www.ameci.cl\/declaracion-salud\/","title":{"rendered":""},"content":{"rendered":"\n<figure class=\"wp-block-image size-large\"><img decoding=\"async\" src=\"https:\/\/www.ameci.cl\/declaracion-salud\/wp-content\/uploads\/2026\/05\/LOGO_AMECI2.png\" alt=\"\"\/><\/figure>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\" style=\"margin-top:var(--wp--preset--spacing--20);margin-bottom:var(--wp--preset--spacing--20)\"\/>\n\n\n<div class='fluentform ff-default fluentform_wrapper_3 ffs_default_wrap'><form data-form_id=\"3\" id=\"fluentform_3\" class=\"frm-fluent-form fluent_form_3 ff-el-form-top ff_form_instance_3_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_3_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Formulario para declaracion de salud<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='11' \/><input type=\"hidden\" id=\"_fluentform_3_fluentformnonce\" name=\"_fluentform_3_fluentformnonce\" value=\"9b82c81b94\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/declaracion-salud\/wp-json\/wp\/v2\/pages\/11\" \/><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_1\" ><h1 style=\"text-align: center\"><strong>DECLARACI\u00d3N DE SALUD DEL TRABAJADOR<\/strong><\/h1><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_2\" ><h2 style=\"text-align: left\"><strong>1.- IDENTIFICACI\u00d3N DEL TRABAJADOR<\/strong><\/h2><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 45.11%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_7' id='label_ff_3_input_text_7' aria-label=\"Nombre completo:\">Nombre completo:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_7\" class=\"ff-el-form-control\" data-name=\"input_text_7\" id=\"ff_3_input_text_7\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_cargo' id='label_ff_3_input_cargo' aria-label=\"Cargo:\">Cargo:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_cargo\" class=\"ff-el-form-control\" data-name=\"input_cargo\" id=\"ff_3_input_cargo\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 54.89%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_mask' id='label_ff_3_input_mask' aria-label=\"Rut:\">Rut:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_mask\" data-mask=\"99.999.999-*\" class=\"ff-el-form-control\" placeholder=\"99.999.999-9\" data-name=\"input_mask\" id=\"ff_3_input_mask\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_fecha_ingreso' id='label_ff_3_input_fecha_ingreso' aria-label=\"Fecha de ingreso\">Fecha de ingreso<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_fecha_ingreso\" data-mask=\"00\/00\/0000\" class=\"ff-el-form-control\" placeholder=\"dd-mm-aaaa\" data-name=\"input_fecha_ingreso\" id=\"ff_3_input_fecha_ingreso\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_3\" ><h2 style=\"text-align: left\"><strong>2.- ANTECEDENTES MEDICOS: Ha tenido o tiene alg\u00fan s\u00edntoma o enfermedad como las descritas a continuaci\u00f3n<\/strong><\/h2><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 88.49%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"1.- Disminuci\u00f3n de visi\u00f3n\">1.- Disminuci\u00f3n de visi\u00f3n<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_1_c0fc5b15ebc74931894ab3fff9e0c526'><input  type=\"radio\" name=\"input_1\" data-name=\"input_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_1_c0fc5b15ebc74931894ab3fff9e0c526' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_1_693c003bc510c540545070c333973839'><input  type=\"radio\" name=\"input_1\" data-name=\"input_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_1_693c003bc510c540545070c333973839' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 11.51%;'><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 90%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"2.- \u00bfDisminuci\u00f3n de la audici\u00f3n\">2.- \u00bfDisminuci\u00f3n de la audici\u00f3n<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_2_cd26822ec8d0329094bec185add5548d'><input  type=\"radio\" name=\"input_2\" data-name=\"input_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_2_cd26822ec8d0329094bec185add5548d' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_2_9753599c12613c01d8a51d124eed4437'><input  type=\"radio\" name=\"input_2\" data-name=\"input_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_2_9753599c12613c01d8a51d124eed4437' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 10%;'><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 90%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"3.- Diabetes\">3.- Diabetes<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_3_77a083a7bf9fe44774fa244c455bf98e'><input  type=\"radio\" name=\"input_3\" data-name=\"input_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_3_77a083a7bf9fe44774fa244c455bf98e' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_3_9c8e18f633359c20a346bc9ea6355ea1'><input  type=\"radio\" name=\"input_3\" data-name=\"input_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_3_9c8e18f633359c20a346bc9ea6355ea1' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 10%;'><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"4.- Secuela de accidentes y\/o enfermedades no laborales\">4.- Secuela de accidentes y\/o enfermedades no laborales<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_4_e92b2e695955a42bd4611355f24be57d'><input  type=\"radio\" name=\"input_4\" data-name=\"input_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_4_e92b2e695955a42bd4611355f24be57d' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_4_6ece78d2ef16dfb7527c61549d92ba3c'><input  type=\"radio\" name=\"input_4\" data-name=\"input_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_4_6ece78d2ef16dfb7527c61549d92ba3c' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_texto_4' id='label_ff_3_input_texto_4' aria-label=\"\u00bfCual?\">\u00bfCual?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_texto_4\" class=\"ff-el-form-control\" data-name=\"input_texto_4\" id=\"ff_3_input_texto_4\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 90%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"5.- Epilepsia\">5.- Epilepsia<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_5_24f63b4e88f562231563d3eeae3a4674'><input  type=\"radio\" name=\"input_5\" data-name=\"input_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_5_24f63b4e88f562231563d3eeae3a4674' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_5_17853e0439194ff0483deb60dfcd57d0'><input  type=\"radio\" name=\"input_5\" data-name=\"input_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_5_17853e0439194ff0483deb60dfcd57d0' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 10%;'><\/div><\/div><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 90%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"6.- V\u00e9rtigo\">6.- V\u00e9rtigo<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_6_75a560391e66efd68136180cc6017886'><input  type=\"radio\" name=\"input_6\" data-name=\"input_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_6_75a560391e66efd68136180cc6017886' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_6_6be960df32edc1be277c46437ec28add'><input  type=\"radio\" name=\"input_6\" data-name=\"input_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_6_6be960df32edc1be277c46437ec28add' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 10%;'><\/div><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 90%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"7.- Tumor o c\u00e1ncer\">7.- Tumor o c\u00e1ncer<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_7_87eb54922561a545e52ebbf4c8b4add2'><input  type=\"radio\" name=\"input_7\" data-name=\"input_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_7_87eb54922561a545e52ebbf4c8b4add2' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_7_6b5e41dd7f12c31650a26ddd11b58ed0'><input  type=\"radio\" name=\"input_7\" data-name=\"input_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_7_6b5e41dd7f12c31650a26ddd11b58ed0' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 10%;'><\/div><\/div><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"8.- Antecedentes cardiovasculares\">8.- Antecedentes cardiovasculares<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_8_d74d1e77517af859259029237d487bf9'><input  type=\"radio\" name=\"input_8\" data-name=\"input_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_8_d74d1e77517af859259029237d487bf9' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_8_9f54e79a188da4881b337f1c42dd4066'><input  type=\"radio\" name=\"input_8\" data-name=\"input_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_8_9f54e79a188da4881b337f1c42dd4066' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_texto_8' id='label_ff_3_input_texto_8' aria-label=\"\u00bfCual?\">\u00bfCual?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_texto_8\" class=\"ff-el-form-control\" data-name=\"input_texto_8\" id=\"ff_3_input_texto_8\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_10\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"9.- Antecedentes de tipo respiratorio\">9.- Antecedentes de tipo respiratorio<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_9_89f73e9d3dae59eeca528a5c4b67097d'><input  type=\"radio\" name=\"input_9\" data-name=\"input_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_9_89f73e9d3dae59eeca528a5c4b67097d' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_9_dbfeca39b0f0bc3ef0534c6ce5dec1db'><input  type=\"radio\" name=\"input_9\" data-name=\"input_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_9_dbfeca39b0f0bc3ef0534c6ce5dec1db' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_texto_9' id='label_ff_3_input_texto_9' aria-label=\"\u00bfCual?\">\u00bfCual?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_texto_9\" class=\"ff-el-form-control\" data-name=\"input_texto_9\" id=\"ff_3_input_texto_9\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_11\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"10.- \u00bfConsume alg\u00fan medicamento?\">10.- \u00bfConsume alg\u00fan medicamento?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_10_92dd31df41a49450d7f25a82d2f259a2'><input  type=\"radio\" name=\"input_10\" data-name=\"input_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_10_92dd31df41a49450d7f25a82d2f259a2' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_10_b01eb86cd452d5e75933a65c7b14fdfd'><input  type=\"radio\" name=\"input_10\" data-name=\"input_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_10_b01eb86cd452d5e75933a65c7b14fdfd' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_texto_10' id='label_ff_3_input_texto_10' aria-label=\"\u00bfCual?\">\u00bfCual?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_texto_10\" class=\"ff-el-form-control\" data-name=\"input_texto_10\" id=\"ff_3_input_texto_10\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_12\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"11.- \u00bfPosee antecedentes de tipo al\u00e9rgico?\">11.- \u00bfPosee antecedentes de tipo al\u00e9rgico?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_11_6e79ab0b5e8495420e9b26ff23fa1c01'><input  type=\"radio\" name=\"input_11\" data-name=\"input_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_11_6e79ab0b5e8495420e9b26ff23fa1c01' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_11_0a690ea403fa180bebd438a1a2ace468'><input  type=\"radio\" name=\"input_11\" data-name=\"input_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_11_0a690ea403fa180bebd438a1a2ace468' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_texto_11' id='label_ff_3_input_texto_11' aria-label=\"\u00bfCual?\">\u00bfCual?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_texto_11\" class=\"ff-el-form-control\" data-name=\"input_texto_11\" id=\"ff_3_input_texto_11\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_13\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"12.- \u00bfHa sido alguna vez operado?\">12.- \u00bfHa sido alguna vez operado?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_e842855d393640a03bcd45ad56f5d918'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_radio_e842855d393640a03bcd45ad56f5d918' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_b37bcc251632196a349f1ab9a1ec706c'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_radio_b37bcc251632196a349f1ab9a1ec706c' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text' id='label_ff_3_input_text' aria-label=\"Se\u00f1ale\">Se\u00f1ale<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_3_input_text\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_14\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"13.- \u00bfSufre de alguna enfermedad cr\u00f3nica? (Lumbago, Tendinitis, etc.)\">13.- \u00bfSufre de alguna enfermedad cr\u00f3nica? (Lumbago, Tendinitis, etc.)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_af11ca4726a58c9b2315af30251b8667'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_radio_2_af11ca4726a58c9b2315af30251b8667' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_14327aaf6db1a31eb4d670d5bace1260'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_radio_2_14327aaf6db1a31eb4d670d5bace1260' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_2' id='label_ff_3_input_text_2' aria-label=\"\u00bfCu\u00e1l?\">\u00bfCu\u00e1l?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_3_input_text_2\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_15\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"14.- \u00bfSufre de presi\u00f3n arterial? (Hipertensi\u00f3n, etc.)\">14.- \u00bfSufre de presi\u00f3n arterial? (Hipertensi\u00f3n, etc.)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_b4f4397500c273b8e46a53a603288053'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_radio_1_b4f4397500c273b8e46a53a603288053' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_f7bbf13347291f0a0ee3f85f89517ca4'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_radio_1_f7bbf13347291f0a0ee3f85f89517ca4' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_1' id='label_ff_3_input_text_1' aria-label=\"Se\u00f1ale\">Se\u00f1ale<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_3_input_text_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_16\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"15.- \u00bfConsume o ha consumido Alcohol?\">15.- \u00bfConsume o ha consumido Alcohol?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_99e6f78a962bc1fe27c3740b2c0bba9d'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_radio_5_99e6f78a962bc1fe27c3740b2c0bba9d' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_0a9ec40b86eb7ba83b28a500eab71515'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_radio_5_0a9ec40b86eb7ba83b28a500eab71515' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfCon que frecuencia?\">\u00bfCon que frecuencia?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_98f3db14d9d2db4206b6df013b5c2c74'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Todos los dias\"  id='input_radio_7_98f3db14d9d2db4206b6df013b5c2c74' aria-label='Todos los dias' aria-invalid='false' aria-required=true> <span>Todos los dias<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_bd13ee0ce3f70030efbcb07e3d52feb1'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"En ocasiones\"  id='input_radio_7_bd13ee0ce3f70030efbcb07e3d52feb1' aria-label='En ocasiones' aria-invalid='false' aria-required=true> <span>En ocasiones<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_33929609e889a0398e7b2fdad316d920'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Rara vez\"  id='input_radio_7_33929609e889a0398e7b2fdad316d920' aria-label='Rara vez' aria-invalid='false' aria-required=true> <span>Rara vez<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfCuanto consume?\">\u00bfCuanto consume?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_e858add2b764d7d6c4579dd551790515'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Mas de 3 vasos\"  id='input_radio_8_e858add2b764d7d6c4579dd551790515' aria-label='Mas de 3 vasos' aria-invalid='false' aria-required=true> <span>Mas de 3 vasos<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_9415302235571bfc6103b8948e7d5c64'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"De 2 a 3 vasos\"  id='input_radio_8_9415302235571bfc6103b8948e7d5c64' aria-label='De 2 a 3 vasos' aria-invalid='false' aria-required=true> <span>De 2 a 3 vasos<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_1cce773bf6c2d21360347a98d53561c1'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Solo 1 vaso\"  id='input_radio_8_1cce773bf6c2d21360347a98d53561c1' aria-label='Solo 1 vaso' aria-invalid='false' aria-required=true> <span>Solo 1 vaso<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_17\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"16.- \u00bfEs usted fumador?\">16.- \u00bfEs usted fumador?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_6a2d75e2ff1d6d5f5c4d775c17937b72'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_radio_4_6a2d75e2ff1d6d5f5c4d775c17937b72' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_1941b1eb4eff9cc98d7a9f93457f3f6f'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_radio_4_1941b1eb4eff9cc98d7a9f93457f3f6f' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_4' id='label_ff_3_input_text_4' aria-label=\"\u00bfCuanto fuma al dia?\">\u00bfCuanto fuma al dia?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" data-name=\"input_text_4\" id=\"ff_3_input_text_4\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_18\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"17.- \u00bfConsume o ha consumido drogas (marihuana, coca\u00edna, pasta base, etc.)?\">17.- \u00bfConsume o ha consumido drogas (marihuana, coca\u00edna, pasta base, etc.)?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_2ec20b7eb37b3a109dc24323600a118b'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_radio_3_2ec20b7eb37b3a109dc24323600a118b' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_8bc0562bd4ecb4c31818bdec9cb471d9'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_radio_3_8bc0562bd4ecb4c31818bdec9cb471d9' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_3' id='label_ff_3_input_text_3' aria-label=\"\u00bfCual?\">\u00bfCual?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_3\" class=\"ff-el-form-control\" data-name=\"input_text_3\" id=\"ff_3_input_text_3\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_4\" ><h2 style=\"text-align: left\"><strong>3.- PATOLOG\u00cdAS DE ORIGEN LABORAL<\/strong><\/h2><\/div><div data-name=\"ff_cn_id_19\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfHa sido evaluado por enfermedad profesional?\">\u00bfHa sido evaluado por enfermedad profesional?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hsepep_425ebe5f2c693877a597f8bb3061810d'><input  type=\"radio\" name=\"input_hsepep\" data-name=\"input_hsepep\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_hsepep_425ebe5f2c693877a597f8bb3061810d' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hsepep_b4c45b47086a6f374c909e2b4f3c46fd'><input  type=\"radio\" name=\"input_hsepep\" data-name=\"input_hsepep\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_hsepep_b4c45b47086a6f374c909e2b4f3c46fd' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_anio' id='label_ff_3_input_anio' aria-label=\"A\u00f1o\">A\u00f1o<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_anio\" class=\"ff-el-form-control\" data-name=\"input_anio\" id=\"ff_3_input_anio\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_empresa' id='label_ff_3_input_empresa' aria-label=\"Empresa\">Empresa<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_empresa\" class=\"ff-el-form-control\" data-name=\"input_empresa\" id=\"ff_3_input_empresa\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_20\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfHa sufrido alg\u00fan accidente?\">\u00bfHa sufrido alg\u00fan accidente?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hsac_e0e7330afcd02e1196464c76f0466e3e'><input  type=\"radio\" name=\"input_hsac\" data-name=\"input_hsac\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_hsac_e0e7330afcd02e1196464c76f0466e3e' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hsac_8f4848affc8842dec67813abc25d38cc'><input  type=\"radio\" name=\"input_hsac\" data-name=\"input_hsac\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_hsac_8f4848affc8842dec67813abc25d38cc' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_cual' id='label_ff_3_input_cual' aria-label=\"\u00bfCual?\">\u00bfCual?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_cual\" class=\"ff-el-form-control\" data-name=\"input_cual\" id=\"ff_3_input_cual\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_mlesiones' id='label_ff_3_input_mlesiones' aria-label=\"Mencione Lesiones\">Mencione Lesiones<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_mlesiones\" class=\"ff-el-form-control\" data-name=\"input_mlesiones\" id=\"ff_3_input_mlesiones\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_21\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group has-conditions  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfEl accidente fue dentro del trabajo?\">\u00bfEl accidente fue dentro del trabajo?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_eafddt_2487e808bcfa72340208e994bcbd576d'><input  type=\"radio\" name=\"input_eafddt\" data-name=\"input_eafddt\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_eafddt_2487e808bcfa72340208e994bcbd576d' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_eafddt_17dfde95fc7a3dee79f9a51f4af417a7'><input  type=\"radio\" name=\"input_eafddt\" data-name=\"input_eafddt\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_eafddt_17dfde95fc7a3dee79f9a51f4af417a7' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_anio_eafddt' id='label_ff_3_input_anio_eafddt' aria-label=\"A\u00f1o\">A\u00f1o<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_anio_eafddt\" class=\"ff-el-form-control\" data-name=\"input_anio_eafddt\" id=\"ff_3_input_anio_eafddt\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_eafddt_empresa' id='label_ff_3_input_eafddt_empresa' aria-label=\"Empresa\">Empresa<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_eafddt_empresa\" class=\"ff-el-form-control\" data-name=\"input_eafddt_empresa\" id=\"ff_3_input_eafddt_empresa\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_22\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 49.55%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfHa trabajado anteriormente expuesto a agentes de riesgo?\">\u00bfHa trabajado anteriormente expuesto a agentes de riesgo?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_htaeaadr_e7ea4c265f76cca41b66babecb798245'><input  type=\"radio\" name=\"input_htaeaadr\" data-name=\"input_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_htaeaadr_e7ea4c265f76cca41b66babecb798245' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_htaeaadr_bda6cbbb6d18df1341bdbef9e62bde5d'><input  type=\"radio\" name=\"input_htaeaadr\" data-name=\"input_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_htaeaadr_bda6cbbb6d18df1341bdbef9e62bde5d' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50.45%;'><div class='ff-el-group has-conditions  ff_list_2col'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Selecciona la\/las opci\u00f3n\/es\">Selecciona la\/las opci\u00f3n\/es<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_htaeaadr_a2cf5d9e047eab14bfd67ba60ce9f96a'><input  type=\"checkbox\" name=\"checkbox_htaeaadr[]\" data-name=\"checkbox_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ruido\"  id='checkbox_htaeaadr_a2cf5d9e047eab14bfd67ba60ce9f96a' aria-label='Ruido' aria-invalid='false' aria-required=true> <span>Ruido<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_htaeaadr_113de57e83997eab72cfc9dfc4f36365'><input  type=\"checkbox\" name=\"checkbox_htaeaadr[]\" data-name=\"checkbox_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Polvo (S\u00edlice, madera, cemento, etc.)\"  id='checkbox_htaeaadr_113de57e83997eab72cfc9dfc4f36365' aria-label='Polvo (S\u00edlice, madera, cemento, etc.)' aria-invalid='false' aria-required=true> <span>Polvo (S\u00edlice, madera, cemento, etc.)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_htaeaadr_7a12c8698b71039d697c107c9fd3b0d0'><input  type=\"checkbox\" name=\"checkbox_htaeaadr[]\" data-name=\"checkbox_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Sustancias qu\u00edmicas\"  id='checkbox_htaeaadr_7a12c8698b71039d697c107c9fd3b0d0' aria-label='Sustancias qu\u00edmicas' aria-invalid='false' aria-required=true> <span>Sustancias qu\u00edmicas<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_htaeaadr_88a2fe008e430019fe303a7d6432fca9'><input  type=\"checkbox\" name=\"checkbox_htaeaadr[]\" data-name=\"checkbox_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Vibraciones\"  id='checkbox_htaeaadr_88a2fe008e430019fe303a7d6432fca9' aria-label='Vibraciones' aria-invalid='false' aria-required=true> <span>Vibraciones<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_htaeaadr_30e46314ddc901d1a22e5be25455b719'><input  type=\"checkbox\" name=\"checkbox_htaeaadr[]\" data-name=\"checkbox_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Radiaci\u00f3n UV\"  id='checkbox_htaeaadr_30e46314ddc901d1a22e5be25455b719' aria-label='Radiaci\u00f3n UV' aria-invalid='false' aria-required=true> <span>Radiaci\u00f3n UV<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_htaeaadr_e4c136c9122887993c83490410bcde29'><input  type=\"checkbox\" name=\"checkbox_htaeaadr[]\" data-name=\"checkbox_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Trabajo en altura geogr\u00e1fica\"  id='checkbox_htaeaadr_e4c136c9122887993c83490410bcde29' aria-label='Trabajo en altura geogr\u00e1fica' aria-invalid='false' aria-required=true> <span>Trabajo en altura geogr\u00e1fica<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_htaeaadr_bd05478f5eee4ff821e8d90983e4f524'><input  type=\"checkbox\" name=\"checkbox_htaeaadr[]\" data-name=\"checkbox_htaeaadr\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Otro\"  id='checkbox_htaeaadr_bd05478f5eee4ff821e8d90983e4f524' aria-label='Otro' aria-invalid='false' aria-required=true> <span>Otro<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_texto_htaeaadr' id='label_ff_3_input_texto_htaeaadr' aria-label=\"\u00bfCuales?\">\u00bfCuales?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_texto_htaeaadr\" class=\"ff-el-form-control\" data-name=\"input_texto_htaeaadr\" id=\"ff_3_input_texto_htaeaadr\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_23\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfHa participado en alg\u00fan programa de vigilancia de salud ocupacional?\">\u00bfHa participado en alg\u00fan programa de vigilancia de salud ocupacional?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hpeapdvdso_2a5696216e66fcb777a78ef1ef7cf852'><input  type=\"radio\" name=\"input_hpeapdvdso\" data-name=\"input_hpeapdvdso\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_hpeapdvdso_2a5696216e66fcb777a78ef1ef7cf852' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hpeapdvdso_08d471d88fa7c669a4699c13ab2ace95'><input  type=\"radio\" name=\"input_hpeapdvdso\" data-name=\"input_hpeapdvdso\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_hpeapdvdso_08d471d88fa7c669a4699c13ab2ace95' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_anio_eafddt_2' id='label_ff_3_input_anio_eafddt_2' aria-label=\"\u00bfCu\u00e1l?\">\u00bfCu\u00e1l?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_anio_eafddt_2\" class=\"ff-el-form-control\" data-name=\"input_anio_eafddt_2\" id=\"ff_3_input_anio_eafddt_2\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_24\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfLe han diagnosticado alguna enfermedad relacionada con su trabajo?\">\u00bfLe han diagnosticado alguna enfermedad relacionada con su trabajo?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_eafddt_3_0b21a0cd4ffbf0e91f0eb61ea5957c35'><input  type=\"radio\" name=\"input_eafddt_3\" data-name=\"input_eafddt_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_eafddt_3_0b21a0cd4ffbf0e91f0eb61ea5957c35' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_eafddt_3_23c62c70b031319e001e54e245f9c594'><input  type=\"radio\" name=\"input_eafddt_3\" data-name=\"input_eafddt_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_eafddt_3_23c62c70b031319e001e54e245f9c594' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_cual_lhdaercst' id='label_ff_3_input_cual_lhdaercst' aria-label=\"\u00bfCu\u00e1l?\">\u00bfCu\u00e1l?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_cual_lhdaercst\" class=\"ff-el-form-control\" data-name=\"input_cual_lhdaercst\" id=\"ff_3_input_cual_lhdaercst\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_25\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 49.96%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfPosee alguna restricci\u00f3n m\u00e9dica para realizar actividades laborales?\">\u00bfPosee alguna restricci\u00f3n m\u00e9dica para realizar actividades laborales?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_parmpral_6bb79b0019b9ea0838882cd66efb781e'><input  type=\"radio\" name=\"input_parmpral\" data-name=\"input_parmpral\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_parmpral_6bb79b0019b9ea0838882cd66efb781e' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_parmpral_630f5c3ee3fd093adb13afc7e462f4e7'><input  type=\"radio\" name=\"input_parmpral\" data-name=\"input_parmpral\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_parmpral_630f5c3ee3fd093adb13afc7e462f4e7' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50.04%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_indique_parmpral' id='label_ff_3_input_indique_parmpral' aria-label=\"Indique\">Indique<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_indique_parmpral\" class=\"ff-el-form-control\" data-name=\"input_indique_parmpral\" id=\"ff_3_input_indique_parmpral\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_26\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 49.69%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfHa sufrido anteriormente alg\u00fan accidente del trabajo o enfermedad profesional calificada por el organismo administrador?\">\u00bfHa sufrido anteriormente alg\u00fan accidente del trabajo o enfermedad profesional calificada por el organismo administrador?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hsaaadtoepcpeoa_2473b450428edd6af3d6a2b694cbc2f0'><input  type=\"radio\" name=\"input_hsaaadtoepcpeoa\" data-name=\"input_hsaaadtoepcpeoa\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_hsaaadtoepcpeoa_2473b450428edd6af3d6a2b694cbc2f0' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hsaaadtoepcpeoa_2b60ea784dba7be6424e16358e03a2ab'><input  type=\"radio\" name=\"input_hsaaadtoepcpeoa\" data-name=\"input_hsaaadtoepcpeoa\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"No\"  id='input_hsaaadtoepcpeoa_2b60ea784dba7be6424e16358e03a2ab' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50.31%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_detalle_hsaaadtoepcpeoa' id='label_ff_3_input_detalle_hsaaadtoepcpeoa' aria-label=\"Detalle\">Detalle<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_detalle_hsaaadtoepcpeoa\" class=\"ff-el-form-control\" data-name=\"input_detalle_hsaaadtoepcpeoa\" id=\"ff_3_input_detalle_hsaaadtoepcpeoa\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_27\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 49.69%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"\u00bfHa sido evaluado m\u00e9dicamente por exposici\u00f3n a ruido, s\u00edlice, sustancias qu\u00edmicas u otros agentes ocupacionales?\">\u00bfHa sido evaluado m\u00e9dicamente por exposici\u00f3n a ruido, s\u00edlice, sustancias qu\u00edmicas u otros agentes ocupacionales?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hsempearssquoao_191946294313cc02004a46964e390a84'><input  type=\"radio\" name=\"input_hsempearssquoao\" data-name=\"input_hsempearssquoao\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Si\"  id='input_hsempearssquoao_191946294313cc02004a46964e390a84' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_hsempearssquoao_346d095d78c6703d68a9313524561ad9'><input  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for='ff_3_input_rdle' id='label_ff_3_input_rdle' aria-label=\"Resultado de la evaluaci\u00f3n\">Resultado de la evaluaci\u00f3n<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_rdle\" class=\"ff-el-form-control\" data-name=\"input_rdle\" id=\"ff_3_input_rdle\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_fopdce' id='label_ff_3_input_fopdce' aria-label=\"Frecuencia o periodicidad de control establecida\">Frecuencia o periodicidad de control establecida<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_fopdce\" class=\"ff-el-form-control\" data-name=\"input_fopdce\" id=\"ff_3_input_fopdce\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_5\" ><h4><i>Declaro que la informaci\u00f3n 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