{"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=\"f2248da4f0\" \/><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_2d85dd0ca3b40f15f652d2a01a48a06c'><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_2d85dd0ca3b40f15f652d2a01a48a06c' 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_42ce9d9d88f51ec13b18ead44decb6ef'><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_42ce9d9d88f51ec13b18ead44decb6ef' 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_3cb91be78bd60444c5c55172163816f6'><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_3cb91be78bd60444c5c55172163816f6' 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_07afd5d87df2e1498c8f30d079a8ce99'><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_07afd5d87df2e1498c8f30d079a8ce99' 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_44ba937ce4b22e3c5deb72757d3e0868'><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_44ba937ce4b22e3c5deb72757d3e0868' 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_1823a5b275f4d1426795873e67aaea66'><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_1823a5b275f4d1426795873e67aaea66' 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_c28b744384551a3a1e8d33b3c87b376c'><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_c28b744384551a3a1e8d33b3c87b376c' 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_229c77d99ea44891d2506d7457b00f84'><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_229c77d99ea44891d2506d7457b00f84' 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_ec0f820a947d3aa3539ef627aef24375'><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_ec0f820a947d3aa3539ef627aef24375' 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_8e01fa507eef224db69924a95476f6c7'><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_8e01fa507eef224db69924a95476f6c7' 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_99bd4a653d2dc267ff880c6671bbbc32'><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_99bd4a653d2dc267ff880c6671bbbc32' 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_5da44c538f2ef886a21a4d4e17ad14e4'><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_5da44c538f2ef886a21a4d4e17ad14e4' 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_59d3d93dd06c31ec36e1be88b78079c5'><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_59d3d93dd06c31ec36e1be88b78079c5' 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_70e55779ab82c5ad69886c630497064e'><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_70e55779ab82c5ad69886c630497064e' 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_63ca8f852ed219ce7a572245f324d73c'><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_63ca8f852ed219ce7a572245f324d73c' 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_1426851ff1b0d35e4e42cae0486a6685'><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_1426851ff1b0d35e4e42cae0486a6685' 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_c277c421f368934a8f14eb29a2e05732'><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_c277c421f368934a8f14eb29a2e05732' 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_37528d0be0f58ef1f6594fc00d7255a7'><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_37528d0be0f58ef1f6594fc00d7255a7' 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_1e65e44ef8b3d952a224ce26e3ddef92'><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_1e65e44ef8b3d952a224ce26e3ddef92' 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_477f5dbc9407a49cc37c585691dc8ee3'><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_477f5dbc9407a49cc37c585691dc8ee3' 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_b7400700d1515a0e4f6b875e80560d28'><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_b7400700d1515a0e4f6b875e80560d28' 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_dcefbf7d5007ab593ab50131942bb397'><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_dcefbf7d5007ab593ab50131942bb397' 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_7e7e46c9a5b5a245368f248e8c91642d'><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_7e7e46c9a5b5a245368f248e8c91642d' 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_bd4da431a978354c5d8546948923da6d'><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_bd4da431a978354c5d8546948923da6d' 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_a6e5b8ce931164357e686f4020f53f61'><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_a6e5b8ce931164357e686f4020f53f61' 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_bb8320a7a0b9a3b329d254a4a7f7bd62'><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_bb8320a7a0b9a3b329d254a4a7f7bd62' 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_f4ad2fce500c13f5abae0c293f17c487'><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_f4ad2fce500c13f5abae0c293f17c487' 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_3767162898ad07508824f6435d6decfb'><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_3767162898ad07508824f6435d6decfb' 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_0219477c858b814e15d7067bf838b5af'><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_0219477c858b814e15d7067bf838b5af' 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_8fa78e7d3b7a0f7d8b5087e3686107ab'><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_8fa78e7d3b7a0f7d8b5087e3686107ab' 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_a72d05c453a95c15c2d327cc37ebeb0f'><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_a72d05c453a95c15c2d327cc37ebeb0f' 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_0a9b92e2c2871c050e24e191dbbd3b71'><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_0a9b92e2c2871c050e24e191dbbd3b71' 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_bdf70355c8f30fba53d3d6f00e3b0e63'><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_bdf70355c8f30fba53d3d6f00e3b0e63' 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_03a3ed901feccbaf2618b6ad545b81f4'><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_03a3ed901feccbaf2618b6ad545b81f4' 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_845c838be38d43eecc0b1366ee26620f'><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_845c838be38d43eecc0b1366ee26620f' 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_294504dec273a244121a68b119e01897'><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_294504dec273a244121a68b119e01897' 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_de37ac9baab42a25fd196b46769beea6'><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_de37ac9baab42a25fd196b46769beea6' 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_f2e58450c5a0d3e1f7826a958d0bfef9'><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_f2e58450c5a0d3e1f7826a958d0bfef9' 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_fd3b26b4b007ec1f3f958f0035748006'><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_fd3b26b4b007ec1f3f958f0035748006' 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_28a427dba1cc76c7a584477e47223c62'><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_28a427dba1cc76c7a584477e47223c62' 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_ef1d4af7c175e9b9c1f8de3fa7e00404'><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_ef1d4af7c175e9b9c1f8de3fa7e00404' 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_9d45ec7ce4b284b1e06ab4be4183f897'><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_9d45ec7ce4b284b1e06ab4be4183f897' 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_3eed9f5d01e1a39fb3028cd354c245e6'><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_3eed9f5d01e1a39fb3028cd354c245e6' 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_c61ed6dfb48ea3cf80ea5e25c75e4c35'><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_c61ed6dfb48ea3cf80ea5e25c75e4c35' 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_66d04f675962fe6c66315c3bfd5435c9'><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_66d04f675962fe6c66315c3bfd5435c9' 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_7121c64836f856dda7e54ab08390b753'><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_7121c64836f856dda7e54ab08390b753' 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_cd7e7548bef998912aa320f88be5a38b'><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_cd7e7548bef998912aa320f88be5a38b' 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_97ef36db74a0e7943f2fab7d6169fc96'><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_97ef36db74a0e7943f2fab7d6169fc96' 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_748c4ca7482c02bc3f2b4f19e9253e47'><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_748c4ca7482c02bc3f2b4f19e9253e47' 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_c161f424c74b42545b655fee3678baf2'><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_c161f424c74b42545b655fee3678baf2' 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_dbae7694c08401cc14a516a2c0a65e59'><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_dbae7694c08401cc14a516a2c0a65e59' 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_b1f94258273ce833cd0fdf33e74bf4c3'><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_b1f94258273ce833cd0fdf33e74bf4c3' 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_f78d176c2135cce173c9f718e6e11ede'><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_f78d176c2135cce173c9f718e6e11ede' 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_7a48c63492b62fefd02eaa9e8969f64f'><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_7a48c63492b62fefd02eaa9e8969f64f' 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_505188bf32be41bfe42da3754e26f437'><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_505188bf32be41bfe42da3754e26f437' 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_05d93fd7248fdaf49e463fbaa491d83f'><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_05d93fd7248fdaf49e463fbaa491d83f' 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_52b541de67408c43ea29e3327e230846'><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_52b541de67408c43ea29e3327e230846' 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_8a1a52978adbe13007449f68e5dcdca6'><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_8a1a52978adbe13007449f68e5dcdca6' 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_8fb048975a80f3eb3112e56b78bf6d39'><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_8fb048975a80f3eb3112e56b78bf6d39' 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_fe1487583fbbbebbbc1f2762aea93c37'><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_fe1487583fbbbebbbc1f2762aea93c37' 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_07abedc3f776819c4023ec3343f6cc4b'><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_07abedc3f776819c4023ec3343f6cc4b' 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_c5dd47dad81b8e5d6bf0db1a424726f8'><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_c5dd47dad81b8e5d6bf0db1a424726f8' 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_31579ac2645140c9451077afb5c0a702'><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_31579ac2645140c9451077afb5c0a702' 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_6b6104daf0feeef69911775f8566cc33'><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_6b6104daf0feeef69911775f8566cc33' 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_b364ee16bd7948539091a049c5c02f5e'><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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