{"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=\"4c92d3cdfa\" \/><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_c834e066913414d1d251531a379028f2'><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_c834e066913414d1d251531a379028f2' 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_0c3fd2575ce5f169f6998dcb22c729cd'><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_0c3fd2575ce5f169f6998dcb22c729cd' 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_427c360e1dda4bee55bf7903d1ecad27'><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_427c360e1dda4bee55bf7903d1ecad27' 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_65724e39c8f8389674433ab62282fd34'><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_65724e39c8f8389674433ab62282fd34' 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_4f1d1285d25a9417f3a263e626fbc79a'><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_4f1d1285d25a9417f3a263e626fbc79a' 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_dced9febff624be11a1b9b18e724c06a'><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_dced9febff624be11a1b9b18e724c06a' 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_d67283b850b556825bf75c90227dcd55'><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_d67283b850b556825bf75c90227dcd55' 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_e07f7a480b08f1dc63da3f7e0b366aca'><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_e07f7a480b08f1dc63da3f7e0b366aca' 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_f0bec3c43509ab68e3e58f7736a1f3cf'><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_f0bec3c43509ab68e3e58f7736a1f3cf' 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_5bd3a74417160515c47fff4834b38151'><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_5bd3a74417160515c47fff4834b38151' 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_8fe2f9452efd5c4ca894e2bd07c9c31e'><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_8fe2f9452efd5c4ca894e2bd07c9c31e' 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_7fd2a17012be9ad5cf8ef75a62ada86e'><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_7fd2a17012be9ad5cf8ef75a62ada86e' 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_b492738487f401833c27c92583d58db8'><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_b492738487f401833c27c92583d58db8' 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_9eedd6b10ca69816973b187136f1cd11'><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_9eedd6b10ca69816973b187136f1cd11' 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_27b4ab05184b657fa632cb07419e2786'><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_27b4ab05184b657fa632cb07419e2786' 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_9ee10d3dab23d09b6206731e609cf2c9'><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_9ee10d3dab23d09b6206731e609cf2c9' 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_efb495a266dc61b1954c611385ef57a5'><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_efb495a266dc61b1954c611385ef57a5' 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_9d55519291ab1a280671a9ee740f10f1'><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_9d55519291ab1a280671a9ee740f10f1' 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_3553d1310e85cc3a23a4a86f63c1ff3d'><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_3553d1310e85cc3a23a4a86f63c1ff3d' 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_febbf2901d5ddeed66807a8476bcd946'><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_febbf2901d5ddeed66807a8476bcd946' 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_005fae651fe82871815d640debd46efc'><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_005fae651fe82871815d640debd46efc' 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_c47ee0514fd3fbeea469afad1855ff02'><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_c47ee0514fd3fbeea469afad1855ff02' 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_09b0dea55451331a7b333fb7b4865c3b'><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_09b0dea55451331a7b333fb7b4865c3b' 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_27539dbfeb08ddc34d764c9d5ae286ba'><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_27539dbfeb08ddc34d764c9d5ae286ba' 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_a4a264811c33eac66e79d86efc360295'><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_a4a264811c33eac66e79d86efc360295' 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_9801d314905fd88cfa6078ecd66685a5'><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_9801d314905fd88cfa6078ecd66685a5' 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_8566b830501aeca7f38f3324d9cd0108'><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_8566b830501aeca7f38f3324d9cd0108' 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_5eeafc3648245d319e1599e985c99df7'><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_5eeafc3648245d319e1599e985c99df7' 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_63342b1aa332430d3d39110353f0972e'><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_63342b1aa332430d3d39110353f0972e' 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_ea8fbc7679cd2ecc69fd8b2e50da54c5'><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_ea8fbc7679cd2ecc69fd8b2e50da54c5' 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_66cf12d5b71cd4675a0c9b71d077f9f3'><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_66cf12d5b71cd4675a0c9b71d077f9f3' 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_f9373fd6a24327d7f5bd9a2cc16bf591'><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_f9373fd6a24327d7f5bd9a2cc16bf591' 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_305a1de454a98b53d027af738365ec1d'><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_305a1de454a98b53d027af738365ec1d' 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_8a87554322713c8b9aa5960c3398221f'><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_8a87554322713c8b9aa5960c3398221f' 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_7e2b8d4933c00618484cdc0f8baaeae7'><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_7e2b8d4933c00618484cdc0f8baaeae7' 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_6a81f61dc68a85f65f72743bcf0960f7'><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_6a81f61dc68a85f65f72743bcf0960f7' 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_594011e90c05cab22ccfc85d6f674893'><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_594011e90c05cab22ccfc85d6f674893' 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_c7884c32fc5ee9e55800851f96c7ae91'><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_c7884c32fc5ee9e55800851f96c7ae91' 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_0fb9d4898ccbabcd4e41f9a8017b53ea'><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_0fb9d4898ccbabcd4e41f9a8017b53ea' 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_be66cdfd58333e5086e584e0a2d4b9e6'><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_be66cdfd58333e5086e584e0a2d4b9e6' 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_69cdbedd5e6d41268b759111a2dfc1b6'><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_69cdbedd5e6d41268b759111a2dfc1b6' 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_4df2a480af1f5041a10c04054f0e5bd1'><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_4df2a480af1f5041a10c04054f0e5bd1' 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_6dbcb95228393ad165832d18a774dd3f'><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_6dbcb95228393ad165832d18a774dd3f' 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_41badeb6923b8fcb6538c567fc23c0dd'><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_41badeb6923b8fcb6538c567fc23c0dd' 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_6e3b240d59ecf0fb3fa50ff0df6969e2'><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_6e3b240d59ecf0fb3fa50ff0df6969e2' 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_ce310a0328072531fe62d23506f79e4b'><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_ce310a0328072531fe62d23506f79e4b' 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_83d211a3dc587720dfc425d2a6c6d8b2'><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_83d211a3dc587720dfc425d2a6c6d8b2' 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_f8733ff386ef9ff6b75e08c0274570e8'><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_f8733ff386ef9ff6b75e08c0274570e8' 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_81d5a6e6a70cefaac33dc8fa2686a133'><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_81d5a6e6a70cefaac33dc8fa2686a133' 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_471bd78bc3e9b6eb4da471790f16a6a4'><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_471bd78bc3e9b6eb4da471790f16a6a4' 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_d4a886d76199568e346699b6bc5ba176'><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_d4a886d76199568e346699b6bc5ba176' 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_d220b63ed135e118f3526fd4953a920f'><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_d220b63ed135e118f3526fd4953a920f' 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_8eb3751bc7b3f7c0b1e626eb15b0339a'><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_8eb3751bc7b3f7c0b1e626eb15b0339a' 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_e1925cb08637f423853760cab6e6e0e4'><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_e1925cb08637f423853760cab6e6e0e4' 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_10452369916313b70a89fe9eb8626e69'><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_10452369916313b70a89fe9eb8626e69' 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_6c4818707aed76fd36821c00e8528fbb'><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_6c4818707aed76fd36821c00e8528fbb' 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_5656829ae13d52e1b3b5d9cf4a43acf4'><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_5656829ae13d52e1b3b5d9cf4a43acf4' 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_893dc69f1a7c34342062b45ca3389929'><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_893dc69f1a7c34342062b45ca3389929' 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_41330675318ebd617b68a9166d51c580'><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_41330675318ebd617b68a9166d51c580' 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_384f0150b2826555ec62d0d35b4f23cb'><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_384f0150b2826555ec62d0d35b4f23cb' 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_787a8a6ee3c5ec3a3c5800d77c4e614f'><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_787a8a6ee3c5ec3a3c5800d77c4e614f' 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_be88a47fb40cc0bccb6ea9a2bfc2a661'><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_be88a47fb40cc0bccb6ea9a2bfc2a661' 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_7410b82458d4c9d8f53cbfd82851e97a'><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_7410b82458d4c9d8f53cbfd82851e97a' 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_38d3b2bbb74234cf07ea38f67a8615cd'><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_38d3b2bbb74234cf07ea38f67a8615cd' 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_745bf506999026ce06746f00b45c1d03'><input  type=\"radio\" name=\"input_hsempearssquoao\" data-name=\"input_hsempearssquoao\" class=\"ff-el-form-check-input 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