{"id":29990,"date":"2019-04-10T17:19:41","date_gmt":"2019-04-10T15:19:41","guid":{"rendered":"https:\/\/opiatest.com\/autoevaluacion-de-la-adecuacion-de-la-dosis-de-su-tratamiento-de-mantenimiento-con-sustitutivos-opiaceos\/"},"modified":"2019-04-10T17:23:41","modified_gmt":"2019-04-10T15:23:41","slug":"odas","status":"publish","type":"page","link":"https:\/\/opiatest.com\/es\/odas\/","title":{"rendered":"Autoevaluaci\u00f3n de la adecuaci\u00f3n de la dosis de su tratamiento de mantenimiento con sustitutivos opi\u00e1ceos."},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;section&#8221; _builder_version=&#8221;3.0.47&#8243; custom_padding=&#8221;26px|0px|54px|0px|false|false&#8221;][et_pb_row custom_padding=&#8221;0|0px|27px|0px|false|false&#8221; admin_label=&#8221;row&#8221; _builder_version=&#8221;3.0.48&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221;][et_pb_column 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gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework form_test_avaluacio_wrapper' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_1' class='form_test_avaluacio' action='\/es\/wp-json\/wp\/v2\/pages\/29990#gf_1' data-formid='1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero='1'>\n        \t<h3 class=\"gf_progressbar_title\">Paso <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>8<\/span> - Tratamiento sustitutivo con agonistas opioides\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_green' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_green percentbar_0' style='width:0%;'><span>0%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_49\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_49\" ><h2 class=\"gsection_title\">Tratamiento sustitutivo con agonistas opioides<\/h2><\/li><li id=\"field_1_32\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_32\" ><label class='gfield_label gform-field-label' >Tipo de tratamiento de sustituci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_32'>\n\t\t\t<li class='gchoice gchoice_1_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='M\u00e9thadone'  id='choice_1_32_0'    \/>\n\t\t\t\t<label for='choice_1_32_0' id='label_1_32_0' class='gform-field-label gform-field-label--type-inline'>Metadona<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='Morphine retard SROM'  id='choice_1_32_1'    \/>\n\t\t\t\t<label for='choice_1_32_1' id='label_1_32_1' class='gform-field-label gform-field-label--type-inline'>Morfina de acci\u00f3n retardada<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_32_2'>\n\t\t\t\t<input name='input_32' type='radio' value='Bupr\u00e9norphine'  id='choice_1_32_2'    \/>\n\t\t\t\t<label for='choice_1_32_2' id='label_1_32_2' class='gform-field-label gform-field-label--type-inline'>Buprenorfina<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_122\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_122\" ><br><\/li><li id=\"field_1_35\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\" ><label class='gfield_label gform-field-label' for='input_1_35'>Dosis de metadona (mg\/d)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_35' id='input_1_35' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_37\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\" ><label class='gfield_label gform-field-label' for='input_1_37'>Dosis de mofina de acci\u00f3n retardada (mg\/d)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_37' id='input_1_37' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_36\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\" ><label class='gfield_label gform-field-label' for='input_1_36'>Dosis de buprenorfina (mg\/d)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_36' id='input_1_36' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_34\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\" ><label class='gfield_label gform-field-label' for='input_1_34'>Duraci\u00f3n de la cura actual (n\u00famero de semanas)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_34' id='input_1_34' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_50' class='gform_next_button gform-theme-button button' value='Siguiente'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-50' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_114\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_114\" ><h2 class=\"gsection_title\">Consumo(s)<\/h2><\/li><li id=\"field_1_74\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_74\" ><label class='gfield_label gform-field-label' >En los \u00faltimos 7 d\u00edas, \u00bfcu\u00e1ntas veces ha usado hero\u00edna u otro op\u00efode fuera del tratamiento prescrito?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_74'>\n\t\t\t<li class='gchoice gchoice_1_74_0'>\n\t\t\t\t<input name='input_74' type='radio' value='5'  id='choice_1_74_0'    \/>\n\t\t\t\t<label for='choice_1_74_0' id='label_1_74_0' class='gform-field-label gform-field-label--type-inline'>Ninguna<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_74_1'>\n\t\t\t\t<input name='input_74' type='radio' value='4'  id='choice_1_74_1'    \/>\n\t\t\t\t<label for='choice_1_74_1' id='label_1_74_1' class='gform-field-label gform-field-label--type-inline'>Una, dos o tres veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_74_2'>\n\t\t\t\t<input name='input_74' type='radio' value='3'  id='choice_1_74_2'    \/>\n\t\t\t\t<label for='choice_1_74_2' id='label_1_74_2' class='gform-field-label gform-field-label--type-inline'>Cuatro, cinco o seis veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_74_3'>\n\t\t\t\t<input name='input_74' type='radio' value='2'  id='choice_1_74_3'    \/>\n\t\t\t\t<label for='choice_1_74_3' id='label_1_74_3' class='gform-field-label gform-field-label--type-inline'>Una o dos veces al d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_74_4'>\n\t\t\t\t<input name='input_74' type='radio' value='1'  id='choice_1_74_4'    \/>\n\t\t\t\t<label for='choice_1_74_4' id='label_1_74_4' class='gform-field-label gform-field-label--type-inline'>Tres o m\u00e1s veces al d\u00eda<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_123\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_123\" ><br><\/li><li id=\"field_1_75\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_75\" ><label class='gfield_label gform-field-label' >Durante estos consumos opioides, usted sentio :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_75'>\n\t\t\t<li class='gchoice gchoice_1_75_0'>\n\t\t\t\t<input name='input_75' type='radio' value='5'  id='choice_1_75_0'    \/>\n\t\t\t\t<label for='choice_1_75_0' id='label_1_75_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan efecto<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_75_1'>\n\t\t\t\t<input name='input_75' type='radio' value='4'  id='choice_1_75_1'    \/>\n\t\t\t\t<label for='choice_1_75_1' id='label_1_75_1' class='gform-field-label gform-field-label--type-inline'>Un efecto ligero<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_75_2'>\n\t\t\t\t<input name='input_75' type='radio' value='3'  id='choice_1_75_2'    \/>\n\t\t\t\t<label for='choice_1_75_2' id='label_1_75_2' class='gform-field-label gform-field-label--type-inline'>Un efecto relativamente intenso<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_75_3'>\n\t\t\t\t<input name='input_75' type='radio' value='2'  id='choice_1_75_3'    \/>\n\t\t\t\t<label for='choice_1_75_3' id='label_1_75_3' class='gform-field-label gform-field-label--type-inline'>Un efecto intenso<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_75_4'>\n\t\t\t\t<input name='input_75' type='radio' value='1'  id='choice_1_75_4'    \/>\n\t\t\t\t<label for='choice_1_75_4' id='label_1_75_4' class='gform-field-label gform-field-label--type-inline'>Un efecto extremadamente intenso<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_31\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_31\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_31'>Consommation(s) ok<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_1_31' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_78\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_78\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_78'>Consommation(s) ok<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_1_78' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_77\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_77\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_77'>Consommation(s) pas ok<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_1_77' type='text' value='PAS OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_51' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Anterior'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_51' class='gform_next_button gform-theme-button button' value='Siguiente'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-51' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_53\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_53\" ><h2 class=\"gsection_title\">Signos de abstinencia<\/h2><div class='gsection_description' id='gfield_description_1_53'><br>Los signos de abstinencia son manifestaciones f\u00edsicas objetivas relacionadas con la falta de opi\u00e1ceos que otros pueden observar.<\/div><\/li><li id=\"field_1_100\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_100\" ><label class='gfield_label gform-field-label' >En los \u00faltimos 7 d\u00edas, \u00bfha mostrado alg\u00fan signo de abstinencia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_100'>Por ejemplo: piel de gallina, secreci\u00f3n nasal, bostezo, ojos llorosos, sudoraci\u00f3n, n\u00e1useas o v\u00f3mitos, temblor de manos, agitaci\u00f3n psicomotriz o irritabilidad<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_100'>\n\t\t\t<li class='gchoice gchoice_1_100_0'>\n\t\t\t\t<input name='input_100' type='radio' value='0'  id='choice_1_100_0'    \/>\n\t\t\t\t<label for='choice_1_100_0' id='label_1_100_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_100_1'>\n\t\t\t\t<input name='input_100' type='radio' value='10'  id='choice_1_100_1'    \/>\n\t\t\t\t<label for='choice_1_100_1' id='label_1_100_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_124\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_124\" ><br><\/li><li id=\"field_1_84\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_84\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfQu\u00e9 signos ha presentado?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_84'><li class='gchoice gchoice_1_84_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.1' type='checkbox'  value='Chair de poule'  id='choice_1_84_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_84_1' id='label_1_84_1' class='gform-field-label gform-field-label--type-inline'>Piel de gallina<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_84_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.2' type='checkbox'  value='Nez qui coule'  id='choice_1_84_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_84_2' id='label_1_84_2' class='gform-field-label gform-field-label--type-inline'>Nariz que fluye<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_84_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.3' type='checkbox'  value='Ba\u0302illements'  id='choice_1_84_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_84_3' id='label_1_84_3' class='gform-field-label gform-field-label--type-inline'>Bostezos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_84_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.4' type='checkbox'  value='Yeux qui pleurent'  id='choice_1_84_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_84_4' id='label_1_84_4' class='gform-field-label gform-field-label--type-inline'>Ojos que lloran<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_84_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.5' type='checkbox'  value='Transpiration'  id='choice_1_84_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_84_5' id='label_1_84_5' class='gform-field-label gform-field-label--type-inline'>Sudaciones<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_84_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.6' type='checkbox'  value='Nause\u0301es ou vomissements'  id='choice_1_84_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_84_6' id='label_1_84_6' class='gform-field-label gform-field-label--type-inline'>N\u00e1useas o v\u00f3mitos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_84_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.7' type='checkbox'  value='Tremblement des mains'  id='choice_1_84_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_84_7' id='label_1_84_7' class='gform-field-label gform-field-label--type-inline'>Temblor de manos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_84_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.8' type='checkbox'  value='Agitation psychomotrice ou irritabilite\u0301'  id='choice_1_84_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_84_8' id='label_1_84_8' class='gform-field-label gform-field-label--type-inline'>Agitaci\u00f3n psicomotriz o irritabilidad<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_125\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_125\" ><br><\/li><li id=\"field_1_81\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_81\" ><label class='gfield_label gform-field-label' >Durante los \u00faltimos 7 d\u00edas, \u00bfcon qu\u00e9 frecuencia ha presentado signos de abstinencia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_81'>\n\t\t\t<li class='gchoice gchoice_1_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='4'  id='choice_1_81_0'    \/>\n\t\t\t\t<label for='choice_1_81_0' id='label_1_81_0' class='gform-field-label gform-field-label--type-inline'>Una o dos veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='3'  id='choice_1_81_1'    \/>\n\t\t\t\t<label for='choice_1_81_1' id='label_1_81_1' class='gform-field-label gform-field-label--type-inline'>Tres a seis veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_81_2'>\n\t\t\t\t<input name='input_81' type='radio' value='2'  id='choice_1_81_2'    \/>\n\t\t\t\t<label for='choice_1_81_2' id='label_1_81_2' class='gform-field-label gform-field-label--type-inline'>Todos los d\u00edas, una o dos veces al d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_81_3'>\n\t\t\t\t<input name='input_81' type='radio' value='1'  id='choice_1_81_3'    \/>\n\t\t\t\t<label for='choice_1_81_3' id='label_1_81_3' class='gform-field-label gform-field-label--type-inline'>Cada d\u00eda, m\u00e1s de dos veces al d\u00eda<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_127\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_127\" ><br><\/li><li id=\"field_1_85\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_85\" ><label class='gfield_label gform-field-label' >\u00bfCu\u00e1l fue el grado de intensidad de los signos de abstinencia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_85'>\n\t\t\t<li class='gchoice gchoice_1_85_0'>\n\t\t\t\t<input name='input_85' type='radio' value='5'  id='choice_1_85_0'    \/>\n\t\t\t\t<label for='choice_1_85_0' id='label_1_85_0' class='gform-field-label gform-field-label--type-inline'>Muy baja<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_85_1'>\n\t\t\t\t<input name='input_85' type='radio' value='4'  id='choice_1_85_1'    \/>\n\t\t\t\t<label for='choice_1_85_1' id='label_1_85_1' class='gform-field-label gform-field-label--type-inline'>Baja<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_85_2'>\n\t\t\t\t<input name='input_85' type='radio' value='3'  id='choice_1_85_2'    \/>\n\t\t\t\t<label for='choice_1_85_2' id='label_1_85_2' class='gform-field-label gform-field-label--type-inline'>Relativamente intensa<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_85_3'>\n\t\t\t\t<input name='input_85' type='radio' value='2'  id='choice_1_85_3'    \/>\n\t\t\t\t<label for='choice_1_85_3' id='label_1_85_3' class='gform-field-label gform-field-label--type-inline'>Intensa<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_85_4'>\n\t\t\t\t<input name='input_85' type='radio' value='1'  id='choice_1_85_4'    \/>\n\t\t\t\t<label for='choice_1_85_4' id='label_1_85_4' class='gform-field-label gform-field-label--type-inline'>Extremadamente intensa<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_96\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_96\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_96'>Signes sevrage ok<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_1_96' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_95\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_95\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_95'>Signes sevrage ok<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_1_95' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_79\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_79\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_79'>Signes sevrage pas ok<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_1_79' type='text' value='PAS OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_93' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Anterior'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_93' class='gform_next_button gform-theme-button button' value='Siguiente'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-93' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_92\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_92\" ><h2 class=\"gsection_title\">S\u00edntomas de abstinencia<\/h2><div class='gsection_description' id='gfield_description_1_92'><br>Los s\u00edntomas de la abstinencia son manifestaciones subjetivas que usted siente, pero que otros no pueden observar. <\/div><\/li><li id=\"field_1_86\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_86\" ><label class='gfield_label gform-field-label' >Durante los \u00faltimos 7 d\u00edas, \u00bfha sufrido de alg\u00fan s\u00edntoma de abstinencia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_86'>Por ejemplo: calambres\/dolores musculares, ansiedad, trastornos del sue\u00f1o, fatiga, escalofr\u00edos\/sensaci\u00f3n de fr\u00edo-calor, falta de apetito<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_86'>\n\t\t\t<li class='gchoice gchoice_1_86_0'>\n\t\t\t\t<input name='input_86' type='radio' value='0'  id='choice_1_86_0'    \/>\n\t\t\t\t<label for='choice_1_86_0' id='label_1_86_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_86_1'>\n\t\t\t\t<input name='input_86' type='radio' value='10'  id='choice_1_86_1'    \/>\n\t\t\t\t<label for='choice_1_86_1' id='label_1_86_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_126\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_126\" ><br><\/li><li id=\"field_1_88\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_88\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfQu\u00e9 s\u00edntomas ha presentado?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_88'><li class='gchoice gchoice_1_88_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.1' type='checkbox'  value='Crampes'  id='choice_1_88_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_88_1' id='label_1_88_1' class='gform-field-label gform-field-label--type-inline'>Calambres<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_88_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.2' type='checkbox'  value='Douleurs musculaires'  id='choice_1_88_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_88_2' id='label_1_88_2' class='gform-field-label gform-field-label--type-inline'>Dolores musculares<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_88_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.3' type='checkbox'  value='Anxie\u0301te\u0301'  id='choice_1_88_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_88_3' id='label_1_88_3' class='gform-field-label gform-field-label--type-inline'>Ansiedad<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_88_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.4' type='checkbox'  value='Troubles du sommeil'  id='choice_1_88_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_88_4' id='label_1_88_4' class='gform-field-label gform-field-label--type-inline'>Trastorno del sue\u00f1o<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_88_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.5' type='checkbox'  value='Fatigue'  id='choice_1_88_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_88_5' id='label_1_88_5' class='gform-field-label gform-field-label--type-inline'>Fatiga<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_88_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.6' type='checkbox'  value='Frissons'  id='choice_1_88_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_88_6' id='label_1_88_6' class='gform-field-label gform-field-label--type-inline'>Escalofr\u00edos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_88_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.7' type='checkbox'  value='Sensation de chaud-froid'  id='choice_1_88_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_88_7' id='label_1_88_7' class='gform-field-label gform-field-label--type-inline'>Sensaci\u00f3n de fr\u00edo-calor<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_88_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.8' type='checkbox'  value='Manque d\u2019appe\u0301tit'  id='choice_1_88_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_88_8' id='label_1_88_8' class='gform-field-label gform-field-label--type-inline'>Falta de apetito<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_128\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_128\" ><br><\/li><li id=\"field_1_87\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_87\" ><label class='gfield_label gform-field-label' >Durante los \u00faltimos 7 d\u00edas, \u00bfcon qu\u00e9 frecuencia ha presentado s\u00edntomas de abstinencia subjetivos?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_87'>\n\t\t\t<li class='gchoice gchoice_1_87_0'>\n\t\t\t\t<input name='input_87' type='radio' value='4'  id='choice_1_87_0'    \/>\n\t\t\t\t<label for='choice_1_87_0' id='label_1_87_0' class='gform-field-label gform-field-label--type-inline'>Una o dos veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_87_1'>\n\t\t\t\t<input name='input_87' type='radio' value='3'  id='choice_1_87_1'    \/>\n\t\t\t\t<label for='choice_1_87_1' id='label_1_87_1' class='gform-field-label gform-field-label--type-inline'>Tres a seis veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_87_2'>\n\t\t\t\t<input name='input_87' type='radio' value='2'  id='choice_1_87_2'    \/>\n\t\t\t\t<label for='choice_1_87_2' id='label_1_87_2' class='gform-field-label gform-field-label--type-inline'>Todos los d\u00edas, una o dos veces al d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_87_3'>\n\t\t\t\t<input name='input_87' type='radio' value='1'  id='choice_1_87_3'    \/>\n\t\t\t\t<label for='choice_1_87_3' id='label_1_87_3' class='gform-field-label gform-field-label--type-inline'>Cada d\u00eda, m\u00e1s de dos veces al d\u00eda<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_129\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_129\" ><br><\/li><li id=\"field_1_89\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_89\" ><label class='gfield_label gform-field-label' >\u00bfCu\u00e1l fue el grado de intensidad de los s\u00edntomas de abstinencia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_89'>\n\t\t\t<li class='gchoice gchoice_1_89_0'>\n\t\t\t\t<input name='input_89' type='radio' value='5'  id='choice_1_89_0'    \/>\n\t\t\t\t<label for='choice_1_89_0' id='label_1_89_0' class='gform-field-label gform-field-label--type-inline'>Muy baja<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_89_1'>\n\t\t\t\t<input name='input_89' type='radio' value='4'  id='choice_1_89_1'    \/>\n\t\t\t\t<label for='choice_1_89_1' id='label_1_89_1' class='gform-field-label gform-field-label--type-inline'>Baja<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_89_2'>\n\t\t\t\t<input name='input_89' type='radio' value='3'  id='choice_1_89_2'    \/>\n\t\t\t\t<label for='choice_1_89_2' id='label_1_89_2' class='gform-field-label gform-field-label--type-inline'>Relativamente intensa<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_89_3'>\n\t\t\t\t<input name='input_89' type='radio' value='2'  id='choice_1_89_3'    \/>\n\t\t\t\t<label for='choice_1_89_3' id='label_1_89_3' class='gform-field-label gform-field-label--type-inline'>Intensa<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_89_4'>\n\t\t\t\t<input name='input_89' type='radio' value='1'  id='choice_1_89_4'    \/>\n\t\t\t\t<label for='choice_1_89_4' id='label_1_89_4' class='gform-field-label gform-field-label--type-inline'>Extremadamente intensa<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_97\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_97\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_97'>symptomes sevrage ok<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_1_97' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_98\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_98\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_98'>sympt\u00f4mes sevrage ok2<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_1_98' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_99\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_99\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_99'>sympt\u00f4mes sevrage pas ok<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_1_99' type='text' value='PAS OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_52' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Anterior'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_52' class='gform_next_button gform-theme-button button' value='Siguiente'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' data-js='page-field-id-52' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_54\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_54\" ><h2 class=\"gsection_title\">Deseo irreprimible de consumir (craving)<\/h2><\/li><li id=\"field_1_80\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_80\" ><label class='gfield_label gform-field-label' >En los \u00faltimos 7 d\u00edas, \u00bfha tenido una necesidad incontenible de tomar hero\u00edna u otros opioides fuera del tratamiento?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_80'>\n\t\t\t<li class='gchoice gchoice_1_80_0'>\n\t\t\t\t<input name='input_80' type='radio' value='0'  id='choice_1_80_0'    \/>\n\t\t\t\t<label for='choice_1_80_0' id='label_1_80_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_80_1'>\n\t\t\t\t<input name='input_80' type='radio' value='10'  id='choice_1_80_1'    \/>\n\t\t\t\t<label for='choice_1_80_1' id='label_1_80_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_130\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_130\" ><br><\/li><li id=\"field_1_101\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_101\" ><label class='gfield_label gform-field-label' >Durante los \u00faltimos 7 d\u00edas, \u00bfcon qu\u00e9 frecuencia ha tenido ese impulso irreprimible?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_101'>\n\t\t\t<li class='gchoice gchoice_1_101_0'>\n\t\t\t\t<input name='input_101' type='radio' value='4'  id='choice_1_101_0'    \/>\n\t\t\t\t<label for='choice_1_101_0' id='label_1_101_0' class='gform-field-label gform-field-label--type-inline'>Una o dos veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_101_1'>\n\t\t\t\t<input name='input_101' type='radio' value='3'  id='choice_1_101_1'    \/>\n\t\t\t\t<label for='choice_1_101_1' id='label_1_101_1' class='gform-field-label gform-field-label--type-inline'>Tres a seis veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_101_2'>\n\t\t\t\t<input name='input_101' type='radio' value='2'  id='choice_1_101_2'    \/>\n\t\t\t\t<label for='choice_1_101_2' id='label_1_101_2' class='gform-field-label gform-field-label--type-inline'>Todos los d\u00edas, una o dos veces al d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_101_3'>\n\t\t\t\t<input name='input_101' type='radio' value='1'  id='choice_1_101_3'    \/>\n\t\t\t\t<label for='choice_1_101_3' id='label_1_101_3' class='gform-field-label gform-field-label--type-inline'>Cada d\u00eda, m\u00e1s de dos veces al d\u00eda<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_131\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_131\" ><br><\/li><li id=\"field_1_102\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_102\" ><label class='gfield_label gform-field-label' >\u00bfCu\u00e1l fue el grado de intensidad de este impulso irreprimible?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_102'>\n\t\t\t<li class='gchoice gchoice_1_102_0'>\n\t\t\t\t<input name='input_102' type='radio' value='5'  id='choice_1_102_0'    \/>\n\t\t\t\t<label for='choice_1_102_0' id='label_1_102_0' class='gform-field-label gform-field-label--type-inline'>Muy baja<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_102_1'>\n\t\t\t\t<input name='input_102' type='radio' value='4'  id='choice_1_102_1'    \/>\n\t\t\t\t<label for='choice_1_102_1' id='label_1_102_1' class='gform-field-label gform-field-label--type-inline'>Baja<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_102_2'>\n\t\t\t\t<input name='input_102' type='radio' value='3'  id='choice_1_102_2'    \/>\n\t\t\t\t<label for='choice_1_102_2' id='label_1_102_2' class='gform-field-label gform-field-label--type-inline'>Relativamente intensa<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_102_3'>\n\t\t\t\t<input name='input_102' type='radio' value='2'  id='choice_1_102_3'    \/>\n\t\t\t\t<label for='choice_1_102_3' id='label_1_102_3' class='gform-field-label gform-field-label--type-inline'>Intensa<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_102_4'>\n\t\t\t\t<input name='input_102' type='radio' value='1'  id='choice_1_102_4'    \/>\n\t\t\t\t<label for='choice_1_102_4' id='label_1_102_4' class='gform-field-label gform-field-label--type-inline'>Extremadamente intensa<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_103\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_103\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_103'>craving ok<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_1_103' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_104\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_104\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_104'>craving ok2<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_1_104' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_105\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_105\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_105'>craving pas ok<\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_1_105' type='text' value='PAS OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_55' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Anterior'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_55' class='gform_next_button gform-theme-button button' value='Siguiente'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_6' class='gform_page' data-js='page-field-id-55' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_56\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_56\" ><h2 class=\"gsection_title\">Signos de sobredosis<\/h2><\/li><li id=\"field_1_107\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_107\" ><label class='gfield_label gform-field-label' >Durante los \u00faltimos 7 d\u00edas, \u00bfha notado alguno de los siguientes s\u00edntomas: quedarse dormido o sedaci\u00f3n, dificultad para hablar, desaceleraci\u00f3n, sensaci\u00f3n de &quot;estar drogado&quot;?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_107'>\n\t\t\t<li class='gchoice gchoice_1_107_0'>\n\t\t\t\t<input name='input_107' type='radio' value='0'  id='choice_1_107_0'    \/>\n\t\t\t\t<label for='choice_1_107_0' id='label_1_107_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_107_1'>\n\t\t\t\t<input name='input_107' type='radio' value='10'  id='choice_1_107_1'    \/>\n\t\t\t\t<label for='choice_1_107_1' id='label_1_107_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_132\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_132\" ><br><\/li><li id=\"field_1_108\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_108\" ><label class='gfield_label gform-field-label' >Durante los \u00faltimos 7 d\u00edas, \u00bfcon qu\u00e9 frecuencia ha presentado estos s\u00edntomas?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_108'>\n\t\t\t<li class='gchoice gchoice_1_108_0'>\n\t\t\t\t<input name='input_108' type='radio' value='4'  id='choice_1_108_0'    \/>\n\t\t\t\t<label for='choice_1_108_0' id='label_1_108_0' class='gform-field-label gform-field-label--type-inline'>Una o dos veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_108_1'>\n\t\t\t\t<input name='input_108' type='radio' value='3'  id='choice_1_108_1'    \/>\n\t\t\t\t<label for='choice_1_108_1' id='label_1_108_1' class='gform-field-label gform-field-label--type-inline'>Tres a seis veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_108_2'>\n\t\t\t\t<input name='input_108' type='radio' value='2'  id='choice_1_108_2'    \/>\n\t\t\t\t<label for='choice_1_108_2' id='label_1_108_2' class='gform-field-label gform-field-label--type-inline'>Todos los d\u00edas, una o dos veces al d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_108_3'>\n\t\t\t\t<input name='input_108' type='radio' value='1'  id='choice_1_108_3'    \/>\n\t\t\t\t<label for='choice_1_108_3' id='label_1_108_3' class='gform-field-label gform-field-label--type-inline'>Cada d\u00eda, m\u00e1s de dos veces al d\u00eda<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_133\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_133\" ><br><\/li><li id=\"field_1_109\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_109\" ><label class='gfield_label gform-field-label' >\u00bfCu\u00e1l fue el grado de intensidad de estos s\u00edntomas?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_109'>\n\t\t\t<li class='gchoice gchoice_1_109_0'>\n\t\t\t\t<input name='input_109' type='radio' value='5'  id='choice_1_109_0'    \/>\n\t\t\t\t<label for='choice_1_109_0' id='label_1_109_0' class='gform-field-label gform-field-label--type-inline'>Muy baja<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_109_1'>\n\t\t\t\t<input name='input_109' type='radio' value='4'  id='choice_1_109_1'    \/>\n\t\t\t\t<label for='choice_1_109_1' id='label_1_109_1' class='gform-field-label gform-field-label--type-inline'>Baja<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_109_2'>\n\t\t\t\t<input name='input_109' type='radio' value='3'  id='choice_1_109_2'    \/>\n\t\t\t\t<label for='choice_1_109_2' id='label_1_109_2' class='gform-field-label gform-field-label--type-inline'>Relativamente intensa<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_109_3'>\n\t\t\t\t<input name='input_109' type='radio' value='2'  id='choice_1_109_3'    \/>\n\t\t\t\t<label for='choice_1_109_3' id='label_1_109_3' class='gform-field-label gform-field-label--type-inline'>Intensa<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_109_4'>\n\t\t\t\t<input name='input_109' type='radio' value='1'  id='choice_1_109_4'    \/>\n\t\t\t\t<label for='choice_1_109_4' id='label_1_109_4' class='gform-field-label gform-field-label--type-inline'>Extremadamente intensa<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_110\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_110\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_110'>surdosage ok<\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_1_110' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_111\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_111\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_111'>surdosage ok2<\/label><div class='ginput_container ginput_container_text'><input name='input_111' id='input_1_111' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_112\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_112\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_112'>surdosage pas ok<\/label><div class='ginput_container ginput_container_text'><input name='input_112' id='input_1_112' type='text' value='PAS OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_12\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_12\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_12'>Surdosage<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='PAS OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_48\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_48\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_48'>SEVRAGE<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_1_48' type='text' value='PAS OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_69\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_69\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_69'>Surdosage_propo<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_1_69' type='text' value='49' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_70\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_70\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_70'>SEVRAGE_propo<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_1_70' type='text' value='51' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_71\" class=\"gfield gfield--type-number gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_71\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_71'>Nombre<\/label><div class='ginput_container ginput_container_number'><input name='input_71' id='input_1_71' type='text' step='any'   value='' class='medium'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_115' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Anterior'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_115' class='gform_next_button gform-theme-button button' value='Siguiente'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"7\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"7\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_7' class='gform_page' data-js='page-field-id-115' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_116\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_116\" ><h2 class=\"gsection_title\">Efectos secundarios<\/h2><\/li><li id=\"field_1_135\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_135\" ><label class='gfield_label gform-field-label' >Durante los \u00faltimos 7 d\u00edas, \u00bfha experimentado alg\u00fan efecto secundario relacionado con el tratamiento?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_135'> Por ejemplo: estre\u00f1imiento, retenci\u00f3n urinaria, aumento de la sudoraci\u00f3n, insomnio o dificultad para conciliar el sue\u00f1o, deterioro de la funci\u00f3n sexual, alteraci\u00f3n menstrual, fatiga, dolores musculares, reacciones adversas, mareos, falta de deseo sexual, dificultades para tener una erecci\u00f3n satisfactoria, dificultades para tener un orgasmo.<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_135'>\n\t\t\t<li class='gchoice gchoice_1_135_0'>\n\t\t\t\t<input name='input_135' type='radio' value='0'  id='choice_1_135_0'    \/>\n\t\t\t\t<label for='choice_1_135_0' id='label_1_135_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_135_1'>\n\t\t\t\t<input name='input_135' type='radio' value='10'  id='choice_1_135_1'    \/>\n\t\t\t\t<label for='choice_1_135_1' id='label_1_135_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_136\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_136\" ><br><\/li><li id=\"field_1_121\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_121\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfCu\u00e1l de los siguientes efectos adversos ha sentido?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_121'><li class='gchoice gchoice_1_121_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.1' type='checkbox'  value='Constipation'  id='choice_1_121_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_1' id='label_1_121_1' class='gform-field-label gform-field-label--type-inline'>Estre\u00f1imiento<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.2' type='checkbox'  value='Re\u0301tention urinaire'  id='choice_1_121_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_2' id='label_1_121_2' class='gform-field-label gform-field-label--type-inline'>Retenci\u00f3n urinaria<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.3' type='checkbox'  value='Transpiration accrue'  id='choice_1_121_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_3' id='label_1_121_3' class='gform-field-label gform-field-label--type-inline'>Aumento de la sudoraci\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.4' type='checkbox'  value='Insomnie ou difficulte\u0301s a\u0300 s\u2019endormir'  id='choice_1_121_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_4' id='label_1_121_4' class='gform-field-label gform-field-label--type-inline'>Insomnio o dificultades para conciliar el sue\u00f1o<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.5' type='checkbox'  value='Alte\u0301ration de la fonction sexuelle'  id='choice_1_121_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_5' id='label_1_121_5' class='gform-field-label gform-field-label--type-inline'>Deterioro de la funci\u00f3n sexual<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.6' type='checkbox'  value='Alte\u0301ration menstruelle'  id='choice_1_121_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_6' id='label_1_121_6' class='gform-field-label gform-field-label--type-inline'>Alteraci\u00f3n menstrual<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.7' type='checkbox'  value='Fatigue'  id='choice_1_121_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_7' id='label_1_121_7' class='gform-field-label gform-field-label--type-inline'>Fatiga<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.8' type='checkbox'  value='Douleur musculaire ou courbatures'  id='choice_1_121_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_8' id='label_1_121_8' class='gform-field-label gform-field-label--type-inline'>Dolor muscular o agujetas<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.9' type='checkbox'  value='Effets inde\u0301sirables'  id='choice_1_121_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_9' id='label_1_121_9' class='gform-field-label gform-field-label--type-inline'>Efectos adversos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.11' type='checkbox'  value='Vertiges'  id='choice_1_121_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_11' id='label_1_121_11' class='gform-field-label gform-field-label--type-inline'>Mareos o v\u00e9rtigo<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.12' type='checkbox'  value='Manque de de\u0301sir sexuel'  id='choice_1_121_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_12' id='label_1_121_12' class='gform-field-label gform-field-label--type-inline'>Falta de deseo sexual<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.13' type='checkbox'  value='Difficulte\u0301s a\u0300 avoir une e\u0301rection satisfaisante'  id='choice_1_121_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_13' id='label_1_121_13' class='gform-field-label gform-field-label--type-inline'>Dificultad para tener una erecci\u00f3n satisfactoria<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.14' type='checkbox'  value='Difficulte\u0301s a\u0300 avoir un orgasme'  id='choice_1_121_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_14' id='label_1_121_14' class='gform-field-label gform-field-label--type-inline'>Dificultad para tener un orgasmo<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_137' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Anterior'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_137' class='gform_next_button gform-theme-button button' value='Siguiente'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"8\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"8\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_8' class='gform_page' data-js='page-field-id-137' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_138\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_138\" ><h2 class=\"gsection_title\">Su opini\u00f3n sobre su dosis<\/h2><\/li><li id=\"field_1_117\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_117\" ><label class='gfield_label gform-field-label' >La dosis de su tratamiento de sustituci\u00f3n le parece:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_117'>\n\t\t\t<li class='gchoice gchoice_1_117_0'>\n\t\t\t\t<input name='input_117' type='radio' value='1'  id='choice_1_117_0'    \/>\n\t\t\t\t<label for='choice_1_117_0' id='label_1_117_0' class='gform-field-label gform-field-label--type-inline'>Totalmente inadecuado<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_117_1'>\n\t\t\t\t<input name='input_117' type='radio' value='2'  id='choice_1_117_1'    \/>\n\t\t\t\t<label for='choice_1_117_1' id='label_1_117_1' class='gform-field-label gform-field-label--type-inline'>Inadecuada<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_117_2'>\n\t\t\t\t<input name='input_117' type='radio' value='3'  id='choice_1_117_2'    \/>\n\t\t\t\t<label for='choice_1_117_2' id='label_1_117_2' class='gform-field-label gform-field-label--type-inline'>Ni adecuada ni inadecuada<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_117_3'>\n\t\t\t\t<input name='input_117' type='radio' value='4'  id='choice_1_117_3'    \/>\n\t\t\t\t<label for='choice_1_117_3' id='label_1_117_3' class='gform-field-label gform-field-label--type-inline'>Adecuada<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_117_4'>\n\t\t\t\t<input name='input_117' type='radio' value='5'  id='choice_1_117_4'    \/>\n\t\t\t\t<label for='choice_1_117_4' id='label_1_117_4' class='gform-field-label gform-field-label--type-inline'>Perfectamente adecuada<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_134\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_134\" ><br><\/li><li id=\"field_1_118\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_118\" ><label class='gfield_label gform-field-label' >Usted piensa que su tratamiento deber\u00eda :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_118'>\n\t\t\t<li class='gchoice gchoice_1_118_0'>\n\t\t\t\t<input name='input_118' type='radio' value='\u00eatre augment\u00e9'  id='choice_1_118_0'    \/>\n\t\t\t\t<label for='choice_1_118_0' id='label_1_118_0' class='gform-field-label gform-field-label--type-inline'>aumentarse<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_118_1'>\n\t\t\t\t<input name='input_118' type='radio' value='\u00eatre diminu\u00e9'  id='choice_1_118_1'    \/>\n\t\t\t\t<label for='choice_1_118_1' id='label_1_118_1' class='gform-field-label gform-field-label--type-inline'>disminuirse<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_118_2'>\n\t\t\t\t<input name='input_118' type='radio' value='\u00eatre maintenu'  id='choice_1_118_2'    \/>\n\t\t\t\t<label for='choice_1_118_2' id='label_1_118_2' class='gform-field-label gform-field-label--type-inline'>mantenerse<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_139\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_139\" ><br><\/li><li id=\"field_1_142\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_142\" ><label class='gfield_label gform-field-label' >\u00bfLe gustar\u00eda recibir una copia por correo electr\u00f3nico de los resultados de esta evaluaci\u00f3n?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_142'>\n\t\t\t<li class='gchoice gchoice_1_142_0'>\n\t\t\t\t<input name='input_142' type='radio' value='Oui'  id='choice_1_142_0'    \/>\n\t\t\t\t<label for='choice_1_142_0' id='label_1_142_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_142_1'>\n\t\t\t\t<input name='input_142' type='radio' value='Non'  id='choice_1_142_1'    \/>\n\t\t\t\t<label for='choice_1_142_1' id='label_1_142_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_143\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_143\" ><label class='gfield_label gform-field-label' for='input_1_143'>E-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_143' id='input_1_143' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_144\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_144\" ><label class='gfield_label gform-field-label' for='input_1_144'>Comments<\/label><div class='ginput_container'><input name='input_144' id='input_1_144' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_144'>Este campo es un campo de validaci\u00f3n y debe quedar sin cambios.<\/div><\/li><\/ul><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_1' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Anterior'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Terminar'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='WyJbXSIsIjAwMGQ3MWMyNWEwY2Q2MjlhMmQ3MjJmNGNiNDU2NTY1Il0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='2' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/div><\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 1, 'https:\/\/opiatest.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_1').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_1');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_1').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_1').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_1').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_1').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_1').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_1').val();gformInitSpinner( 1, 'https:\/\/opiatest.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [1, current_page]);window['gf_submitting_1'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_1').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_1').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [1]);window['gf_submitting_1'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_1').text());}else{jQuery('#gform_1').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"1\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);                if (event && event.defaultPrevented) {                return;         }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_1\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_1\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_1\" );        let postRenderFired = false;                function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            jQuery( document ).trigger( 'gform_post_render', [1, current_page] );            gform.utils.trigger( { event: 'gform\/postRender', native: false, data: { formId: 1, currentPage: current_page } } );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    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false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework form_test_avaluacio_wrapper' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_1' class='form_test_avaluacio' action='\/es\/wp-json\/wp\/v2\/pages\/29990#gf_1' data-formid='1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero='1'>\n        \t<h3 class=\"gf_progressbar_title\">Paso <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>8<\/span> - Tratamiento sustitutivo con agonistas opioides\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_green' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_green percentbar_0' style='width:0%;'><span>0%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_49\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_49\" ><h2 class=\"gsection_title\">Tratamiento sustitutivo con agonistas opioides<\/h2><\/li><li id=\"field_1_32\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_32\" ><label class='gfield_label gform-field-label' >Tipo de tratamiento de sustituci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_32'>\n\t\t\t<li class='gchoice gchoice_1_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='M\u00e9thadone'  id='choice_1_32_0'    \/>\n\t\t\t\t<label for='choice_1_32_0' id='label_1_32_0' class='gform-field-label gform-field-label--type-inline'>Metadona<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='Morphine retard SROM'  id='choice_1_32_1'    \/>\n\t\t\t\t<label for='choice_1_32_1' id='label_1_32_1' class='gform-field-label gform-field-label--type-inline'>Morfina de acci\u00f3n retardada<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_32_2'>\n\t\t\t\t<input name='input_32' type='radio' value='Bupr\u00e9norphine'  id='choice_1_32_2'    \/>\n\t\t\t\t<label for='choice_1_32_2' id='label_1_32_2' class='gform-field-label gform-field-label--type-inline'>Buprenorfina<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_122\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_122\" ><br><\/li><li id=\"field_1_35\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\" ><label class='gfield_label gform-field-label' for='input_1_35'>Dosis de metadona (mg\/d)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_35' id='input_1_35' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_37\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\" ><label class='gfield_label gform-field-label' for='input_1_37'>Dosis de mofina de acci\u00f3n retardada (mg\/d)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_37' id='input_1_37' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_36\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\" ><label class='gfield_label gform-field-label' for='input_1_36'>Dosis de buprenorfina (mg\/d)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_36' id='input_1_36' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_34\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\" ><label class='gfield_label gform-field-label' for='input_1_34'>Duraci\u00f3n de la cura actual (n\u00famero de semanas)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_34' id='input_1_34' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_50' class='gform_next_button gform-theme-button button' value='Siguiente'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-50' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_114\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_114\" ><h2 class=\"gsection_title\">Consumo(s)<\/h2><\/li><li id=\"field_1_74\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_74\" ><label class='gfield_label gform-field-label' >En los \u00faltimos 7 d\u00edas, \u00bfcu\u00e1ntas veces ha usado hero\u00edna u otro op\u00efode fuera del tratamiento prescrito?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_74'>\n\t\t\t<li class='gchoice gchoice_1_74_0'>\n\t\t\t\t<input name='input_74' type='radio' value='5'  id='choice_1_74_0'    \/>\n\t\t\t\t<label for='choice_1_74_0' id='label_1_74_0' class='gform-field-label gform-field-label--type-inline'>Ninguna<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_74_1'>\n\t\t\t\t<input name='input_74' type='radio' value='4'  id='choice_1_74_1'    \/>\n\t\t\t\t<label for='choice_1_74_1' id='label_1_74_1' class='gform-field-label gform-field-label--type-inline'>Una, dos o tres veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_74_2'>\n\t\t\t\t<input name='input_74' type='radio' value='3'  id='choice_1_74_2'    \/>\n\t\t\t\t<label for='choice_1_74_2' id='label_1_74_2' class='gform-field-label gform-field-label--type-inline'>Cuatro, cinco o seis veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_74_3'>\n\t\t\t\t<input name='input_74' type='radio' value='2'  id='choice_1_74_3'    \/>\n\t\t\t\t<label for='choice_1_74_3' id='label_1_74_3' class='gform-field-label gform-field-label--type-inline'>Una o dos veces al d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_74_4'>\n\t\t\t\t<input name='input_74' type='radio' value='1'  id='choice_1_74_4'    \/>\n\t\t\t\t<label for='choice_1_74_4' id='label_1_74_4' class='gform-field-label gform-field-label--type-inline'>Tres o m\u00e1s veces al d\u00eda<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_123\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_123\" ><br><\/li><li id=\"field_1_75\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_75\" ><label class='gfield_label gform-field-label' >Durante estos consumos opioides, usted sentio :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_75'>\n\t\t\t<li class='gchoice gchoice_1_75_0'>\n\t\t\t\t<input name='input_75' type='radio' value='5'  id='choice_1_75_0'    \/>\n\t\t\t\t<label for='choice_1_75_0' id='label_1_75_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan efecto<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_75_1'>\n\t\t\t\t<input name='input_75' type='radio' value='4'  id='choice_1_75_1'    \/>\n\t\t\t\t<label for='choice_1_75_1' id='label_1_75_1' class='gform-field-label gform-field-label--type-inline'>Un efecto ligero<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_75_2'>\n\t\t\t\t<input name='input_75' type='radio' value='3'  id='choice_1_75_2'    \/>\n\t\t\t\t<label for='choice_1_75_2' id='label_1_75_2' class='gform-field-label gform-field-label--type-inline'>Un efecto relativamente intenso<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_75_3'>\n\t\t\t\t<input name='input_75' type='radio' value='2'  id='choice_1_75_3'    \/>\n\t\t\t\t<label for='choice_1_75_3' id='label_1_75_3' class='gform-field-label gform-field-label--type-inline'>Un efecto intenso<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_75_4'>\n\t\t\t\t<input name='input_75' type='radio' value='1'  id='choice_1_75_4'    \/>\n\t\t\t\t<label for='choice_1_75_4' id='label_1_75_4' class='gform-field-label gform-field-label--type-inline'>Un efecto extremadamente intenso<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_31\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_31\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_31'>Consommation(s) ok<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_1_31' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_78\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_78\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_78'>Consommation(s) ok<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_1_78' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_77\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_77\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_77'>Consommation(s) pas ok<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_1_77' type='text' value='PAS OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_51' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Anterior'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_51' class='gform_next_button gform-theme-button button' value='Siguiente'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-51' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_53\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_53\" ><h2 class=\"gsection_title\">Signos de abstinencia<\/h2><div class='gsection_description' id='gfield_description_1_53'><br>Los signos de abstinencia son manifestaciones f\u00edsicas objetivas relacionadas con la falta de opi\u00e1ceos que otros pueden observar.<\/div><\/li><li id=\"field_1_100\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_100\" ><label class='gfield_label gform-field-label' >En los \u00faltimos 7 d\u00edas, \u00bfha mostrado alg\u00fan signo de abstinencia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_100'>Por ejemplo: piel de gallina, secreci\u00f3n nasal, bostezo, ojos llorosos, sudoraci\u00f3n, n\u00e1useas o v\u00f3mitos, temblor de manos, agitaci\u00f3n psicomotriz o irritabilidad<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_100'>\n\t\t\t<li class='gchoice gchoice_1_100_0'>\n\t\t\t\t<input name='input_100' type='radio' value='0'  id='choice_1_100_0'    \/>\n\t\t\t\t<label for='choice_1_100_0' id='label_1_100_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_100_1'>\n\t\t\t\t<input name='input_100' type='radio' value='10'  id='choice_1_100_1'    \/>\n\t\t\t\t<label for='choice_1_100_1' id='label_1_100_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_124\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_124\" ><br><\/li><li id=\"field_1_84\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_84\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfQu\u00e9 signos ha presentado?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_84'><li class='gchoice gchoice_1_84_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.1' type='checkbox'  value='Chair de poule'  id='choice_1_84_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_84_1' id='label_1_84_1' class='gform-field-label gform-field-label--type-inline'>Piel de gallina<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_84_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.2' type='checkbox'  value='Nez qui coule'  id='choice_1_84_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_84_2' id='label_1_84_2' class='gform-field-label gform-field-label--type-inline'>Nariz que fluye<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_84_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.3' type='checkbox'  value='Ba\u0302illements'  id='choice_1_84_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_84_3' id='label_1_84_3' class='gform-field-label gform-field-label--type-inline'>Bostezos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_84_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.4' type='checkbox'  value='Yeux qui pleurent'  id='choice_1_84_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_84_4' id='label_1_84_4' class='gform-field-label gform-field-label--type-inline'>Ojos que lloran<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_84_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.5' type='checkbox'  value='Transpiration'  id='choice_1_84_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_84_5' id='label_1_84_5' class='gform-field-label gform-field-label--type-inline'>Sudaciones<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_84_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.6' type='checkbox'  value='Nause\u0301es ou vomissements'  id='choice_1_84_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_84_6' id='label_1_84_6' class='gform-field-label gform-field-label--type-inline'>N\u00e1useas o v\u00f3mitos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_84_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.7' type='checkbox'  value='Tremblement des mains'  id='choice_1_84_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_84_7' id='label_1_84_7' class='gform-field-label gform-field-label--type-inline'>Temblor de manos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_84_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.8' type='checkbox'  value='Agitation psychomotrice ou irritabilite\u0301'  id='choice_1_84_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_84_8' id='label_1_84_8' class='gform-field-label gform-field-label--type-inline'>Agitaci\u00f3n psicomotriz o irritabilidad<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_125\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_125\" ><br><\/li><li id=\"field_1_81\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_81\" ><label class='gfield_label gform-field-label' >Durante los \u00faltimos 7 d\u00edas, \u00bfcon qu\u00e9 frecuencia ha presentado signos de abstinencia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_81'>\n\t\t\t<li class='gchoice gchoice_1_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='4'  id='choice_1_81_0'    \/>\n\t\t\t\t<label for='choice_1_81_0' id='label_1_81_0' class='gform-field-label gform-field-label--type-inline'>Una o dos veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='3'  id='choice_1_81_1'    \/>\n\t\t\t\t<label for='choice_1_81_1' id='label_1_81_1' class='gform-field-label gform-field-label--type-inline'>Tres a seis veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_81_2'>\n\t\t\t\t<input name='input_81' type='radio' value='2'  id='choice_1_81_2'    \/>\n\t\t\t\t<label for='choice_1_81_2' id='label_1_81_2' class='gform-field-label gform-field-label--type-inline'>Todos los d\u00edas, una o dos veces al d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_81_3'>\n\t\t\t\t<input name='input_81' type='radio' value='1'  id='choice_1_81_3'    \/>\n\t\t\t\t<label for='choice_1_81_3' id='label_1_81_3' class='gform-field-label gform-field-label--type-inline'>Cada d\u00eda, m\u00e1s de dos veces al d\u00eda<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_127\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_127\" ><br><\/li><li id=\"field_1_85\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_85\" ><label class='gfield_label gform-field-label' >\u00bfCu\u00e1l fue el grado de intensidad de los signos de abstinencia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_85'>\n\t\t\t<li class='gchoice gchoice_1_85_0'>\n\t\t\t\t<input name='input_85' type='radio' value='5'  id='choice_1_85_0'    \/>\n\t\t\t\t<label for='choice_1_85_0' id='label_1_85_0' class='gform-field-label gform-field-label--type-inline'>Muy baja<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_85_1'>\n\t\t\t\t<input name='input_85' type='radio' value='4'  id='choice_1_85_1'    \/>\n\t\t\t\t<label for='choice_1_85_1' id='label_1_85_1' class='gform-field-label gform-field-label--type-inline'>Baja<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_85_2'>\n\t\t\t\t<input name='input_85' type='radio' value='3'  id='choice_1_85_2'    \/>\n\t\t\t\t<label for='choice_1_85_2' id='label_1_85_2' class='gform-field-label gform-field-label--type-inline'>Relativamente intensa<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_85_3'>\n\t\t\t\t<input name='input_85' type='radio' value='2'  id='choice_1_85_3'    \/>\n\t\t\t\t<label for='choice_1_85_3' id='label_1_85_3' class='gform-field-label gform-field-label--type-inline'>Intensa<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_85_4'>\n\t\t\t\t<input name='input_85' type='radio' value='1'  id='choice_1_85_4'    \/>\n\t\t\t\t<label for='choice_1_85_4' id='label_1_85_4' class='gform-field-label gform-field-label--type-inline'>Extremadamente intensa<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_96\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_96\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_96'>Signes sevrage ok<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_1_96' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_95\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_95\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_95'>Signes sevrage ok<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_1_95' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_79\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_79\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_79'>Signes sevrage pas ok<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_1_79' type='text' value='PAS OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_93' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Anterior'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_93' class='gform_next_button gform-theme-button button' value='Siguiente'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-93' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_92\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_92\" ><h2 class=\"gsection_title\">S\u00edntomas de abstinencia<\/h2><div class='gsection_description' id='gfield_description_1_92'><br>Los s\u00edntomas de la abstinencia son manifestaciones subjetivas que usted siente, pero que otros no pueden observar. <\/div><\/li><li id=\"field_1_86\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_86\" ><label class='gfield_label gform-field-label' >Durante los \u00faltimos 7 d\u00edas, \u00bfha sufrido de alg\u00fan s\u00edntoma de abstinencia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_86'>Por ejemplo: calambres\/dolores musculares, ansiedad, trastornos del sue\u00f1o, fatiga, escalofr\u00edos\/sensaci\u00f3n de fr\u00edo-calor, falta de apetito<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_86'>\n\t\t\t<li class='gchoice gchoice_1_86_0'>\n\t\t\t\t<input name='input_86' type='radio' value='0'  id='choice_1_86_0'    \/>\n\t\t\t\t<label for='choice_1_86_0' id='label_1_86_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_86_1'>\n\t\t\t\t<input name='input_86' type='radio' value='10'  id='choice_1_86_1'    \/>\n\t\t\t\t<label for='choice_1_86_1' id='label_1_86_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_126\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_126\" ><br><\/li><li id=\"field_1_88\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_88\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfQu\u00e9 s\u00edntomas ha presentado?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_88'><li class='gchoice gchoice_1_88_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.1' type='checkbox'  value='Crampes'  id='choice_1_88_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_88_1' id='label_1_88_1' class='gform-field-label gform-field-label--type-inline'>Calambres<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_88_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.2' type='checkbox'  value='Douleurs musculaires'  id='choice_1_88_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_88_2' id='label_1_88_2' class='gform-field-label gform-field-label--type-inline'>Dolores musculares<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_88_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.3' type='checkbox'  value='Anxie\u0301te\u0301'  id='choice_1_88_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_88_3' id='label_1_88_3' class='gform-field-label gform-field-label--type-inline'>Ansiedad<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_88_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.4' type='checkbox'  value='Troubles du sommeil'  id='choice_1_88_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_88_4' id='label_1_88_4' class='gform-field-label gform-field-label--type-inline'>Trastorno del sue\u00f1o<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_88_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.5' type='checkbox'  value='Fatigue'  id='choice_1_88_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_88_5' id='label_1_88_5' class='gform-field-label gform-field-label--type-inline'>Fatiga<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_88_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.6' type='checkbox'  value='Frissons'  id='choice_1_88_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_88_6' id='label_1_88_6' class='gform-field-label gform-field-label--type-inline'>Escalofr\u00edos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_88_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.7' type='checkbox'  value='Sensation de chaud-froid'  id='choice_1_88_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_88_7' id='label_1_88_7' class='gform-field-label gform-field-label--type-inline'>Sensaci\u00f3n de fr\u00edo-calor<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_88_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.8' type='checkbox'  value='Manque d\u2019appe\u0301tit'  id='choice_1_88_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_88_8' id='label_1_88_8' class='gform-field-label gform-field-label--type-inline'>Falta de apetito<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_128\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_128\" ><br><\/li><li id=\"field_1_87\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_87\" ><label class='gfield_label gform-field-label' >Durante los \u00faltimos 7 d\u00edas, \u00bfcon qu\u00e9 frecuencia ha presentado s\u00edntomas de abstinencia subjetivos?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_87'>\n\t\t\t<li class='gchoice gchoice_1_87_0'>\n\t\t\t\t<input name='input_87' type='radio' value='4'  id='choice_1_87_0'    \/>\n\t\t\t\t<label for='choice_1_87_0' id='label_1_87_0' class='gform-field-label gform-field-label--type-inline'>Una o dos veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_87_1'>\n\t\t\t\t<input name='input_87' type='radio' value='3'  id='choice_1_87_1'    \/>\n\t\t\t\t<label for='choice_1_87_1' id='label_1_87_1' class='gform-field-label gform-field-label--type-inline'>Tres a seis veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_87_2'>\n\t\t\t\t<input name='input_87' type='radio' value='2'  id='choice_1_87_2'    \/>\n\t\t\t\t<label for='choice_1_87_2' id='label_1_87_2' class='gform-field-label gform-field-label--type-inline'>Todos los d\u00edas, una o dos veces al d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_87_3'>\n\t\t\t\t<input name='input_87' type='radio' value='1'  id='choice_1_87_3'    \/>\n\t\t\t\t<label for='choice_1_87_3' id='label_1_87_3' class='gform-field-label gform-field-label--type-inline'>Cada d\u00eda, m\u00e1s de dos veces al d\u00eda<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_129\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_129\" ><br><\/li><li id=\"field_1_89\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_89\" ><label class='gfield_label gform-field-label' >\u00bfCu\u00e1l fue el grado de intensidad de los s\u00edntomas de abstinencia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_89'>\n\t\t\t<li class='gchoice gchoice_1_89_0'>\n\t\t\t\t<input name='input_89' type='radio' value='5'  id='choice_1_89_0'    \/>\n\t\t\t\t<label for='choice_1_89_0' id='label_1_89_0' class='gform-field-label gform-field-label--type-inline'>Muy baja<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_89_1'>\n\t\t\t\t<input name='input_89' type='radio' value='4'  id='choice_1_89_1'    \/>\n\t\t\t\t<label for='choice_1_89_1' id='label_1_89_1' class='gform-field-label gform-field-label--type-inline'>Baja<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_89_2'>\n\t\t\t\t<input name='input_89' type='radio' value='3'  id='choice_1_89_2'    \/>\n\t\t\t\t<label for='choice_1_89_2' id='label_1_89_2' class='gform-field-label gform-field-label--type-inline'>Relativamente intensa<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_89_3'>\n\t\t\t\t<input name='input_89' type='radio' value='2'  id='choice_1_89_3'    \/>\n\t\t\t\t<label for='choice_1_89_3' id='label_1_89_3' class='gform-field-label gform-field-label--type-inline'>Intensa<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_89_4'>\n\t\t\t\t<input name='input_89' type='radio' value='1'  id='choice_1_89_4'    \/>\n\t\t\t\t<label for='choice_1_89_4' id='label_1_89_4' class='gform-field-label gform-field-label--type-inline'>Extremadamente intensa<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_97\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_97\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_97'>symptomes sevrage ok<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_1_97' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_98\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_98\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_98'>sympt\u00f4mes sevrage ok2<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_1_98' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_99\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_99\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_99'>sympt\u00f4mes sevrage pas ok<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_1_99' type='text' value='PAS OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_52' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Anterior'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_52' class='gform_next_button gform-theme-button button' value='Siguiente'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' data-js='page-field-id-52' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_54\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_54\" ><h2 class=\"gsection_title\">Deseo irreprimible de consumir (craving)<\/h2><\/li><li id=\"field_1_80\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_80\" ><label class='gfield_label gform-field-label' >En los \u00faltimos 7 d\u00edas, \u00bfha tenido una necesidad incontenible de tomar hero\u00edna u otros opioides fuera del tratamiento?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_80'>\n\t\t\t<li class='gchoice gchoice_1_80_0'>\n\t\t\t\t<input name='input_80' type='radio' value='0'  id='choice_1_80_0'    \/>\n\t\t\t\t<label for='choice_1_80_0' id='label_1_80_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_80_1'>\n\t\t\t\t<input name='input_80' type='radio' value='10'  id='choice_1_80_1'    \/>\n\t\t\t\t<label for='choice_1_80_1' id='label_1_80_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_130\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_130\" ><br><\/li><li id=\"field_1_101\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_101\" ><label class='gfield_label gform-field-label' >Durante los \u00faltimos 7 d\u00edas, \u00bfcon qu\u00e9 frecuencia ha tenido ese impulso irreprimible?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_101'>\n\t\t\t<li class='gchoice gchoice_1_101_0'>\n\t\t\t\t<input name='input_101' type='radio' value='4'  id='choice_1_101_0'    \/>\n\t\t\t\t<label for='choice_1_101_0' id='label_1_101_0' class='gform-field-label gform-field-label--type-inline'>Una o dos veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_101_1'>\n\t\t\t\t<input name='input_101' type='radio' value='3'  id='choice_1_101_1'    \/>\n\t\t\t\t<label for='choice_1_101_1' id='label_1_101_1' class='gform-field-label gform-field-label--type-inline'>Tres a seis veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_101_2'>\n\t\t\t\t<input name='input_101' type='radio' value='2'  id='choice_1_101_2'    \/>\n\t\t\t\t<label for='choice_1_101_2' id='label_1_101_2' class='gform-field-label gform-field-label--type-inline'>Todos los d\u00edas, una o dos veces al d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_101_3'>\n\t\t\t\t<input name='input_101' type='radio' value='1'  id='choice_1_101_3'    \/>\n\t\t\t\t<label for='choice_1_101_3' id='label_1_101_3' class='gform-field-label gform-field-label--type-inline'>Cada d\u00eda, m\u00e1s de dos veces al d\u00eda<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_131\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_131\" ><br><\/li><li id=\"field_1_102\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_102\" ><label class='gfield_label gform-field-label' >\u00bfCu\u00e1l fue el grado de intensidad de este impulso irreprimible?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_102'>\n\t\t\t<li class='gchoice gchoice_1_102_0'>\n\t\t\t\t<input name='input_102' type='radio' value='5'  id='choice_1_102_0'    \/>\n\t\t\t\t<label for='choice_1_102_0' id='label_1_102_0' class='gform-field-label gform-field-label--type-inline'>Muy baja<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_102_1'>\n\t\t\t\t<input name='input_102' type='radio' value='4'  id='choice_1_102_1'    \/>\n\t\t\t\t<label for='choice_1_102_1' id='label_1_102_1' class='gform-field-label gform-field-label--type-inline'>Baja<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_102_2'>\n\t\t\t\t<input name='input_102' type='radio' value='3'  id='choice_1_102_2'    \/>\n\t\t\t\t<label for='choice_1_102_2' id='label_1_102_2' class='gform-field-label gform-field-label--type-inline'>Relativamente intensa<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_102_3'>\n\t\t\t\t<input name='input_102' type='radio' value='2'  id='choice_1_102_3'    \/>\n\t\t\t\t<label for='choice_1_102_3' id='label_1_102_3' class='gform-field-label gform-field-label--type-inline'>Intensa<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_102_4'>\n\t\t\t\t<input name='input_102' type='radio' value='1'  id='choice_1_102_4'    \/>\n\t\t\t\t<label for='choice_1_102_4' id='label_1_102_4' class='gform-field-label gform-field-label--type-inline'>Extremadamente intensa<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_103\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_103\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_103'>craving ok<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_1_103' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_104\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_104\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_104'>craving ok2<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_1_104' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_105\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_105\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_105'>craving pas ok<\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_1_105' type='text' value='PAS OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_55' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Anterior'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_55' class='gform_next_button gform-theme-button button' value='Siguiente'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_6' class='gform_page' data-js='page-field-id-55' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_56\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_56\" ><h2 class=\"gsection_title\">Signos de sobredosis<\/h2><\/li><li id=\"field_1_107\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_107\" ><label class='gfield_label gform-field-label' >Durante los \u00faltimos 7 d\u00edas, \u00bfha notado alguno de los siguientes s\u00edntomas: quedarse dormido o sedaci\u00f3n, dificultad para hablar, desaceleraci\u00f3n, sensaci\u00f3n de &quot;estar drogado&quot;?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_107'>\n\t\t\t<li class='gchoice gchoice_1_107_0'>\n\t\t\t\t<input name='input_107' type='radio' value='0'  id='choice_1_107_0'    \/>\n\t\t\t\t<label for='choice_1_107_0' id='label_1_107_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_107_1'>\n\t\t\t\t<input name='input_107' type='radio' value='10'  id='choice_1_107_1'    \/>\n\t\t\t\t<label for='choice_1_107_1' id='label_1_107_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_132\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_132\" ><br><\/li><li id=\"field_1_108\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_108\" ><label class='gfield_label gform-field-label' >Durante los \u00faltimos 7 d\u00edas, \u00bfcon qu\u00e9 frecuencia ha presentado estos s\u00edntomas?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_108'>\n\t\t\t<li class='gchoice gchoice_1_108_0'>\n\t\t\t\t<input name='input_108' type='radio' value='4'  id='choice_1_108_0'    \/>\n\t\t\t\t<label for='choice_1_108_0' id='label_1_108_0' class='gform-field-label gform-field-label--type-inline'>Una o dos veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_108_1'>\n\t\t\t\t<input name='input_108' type='radio' value='3'  id='choice_1_108_1'    \/>\n\t\t\t\t<label for='choice_1_108_1' id='label_1_108_1' class='gform-field-label gform-field-label--type-inline'>Tres a seis veces<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_108_2'>\n\t\t\t\t<input name='input_108' type='radio' value='2'  id='choice_1_108_2'    \/>\n\t\t\t\t<label for='choice_1_108_2' id='label_1_108_2' class='gform-field-label gform-field-label--type-inline'>Todos los d\u00edas, una o dos veces al d\u00eda<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_108_3'>\n\t\t\t\t<input name='input_108' type='radio' value='1'  id='choice_1_108_3'    \/>\n\t\t\t\t<label for='choice_1_108_3' id='label_1_108_3' class='gform-field-label gform-field-label--type-inline'>Cada d\u00eda, m\u00e1s de dos veces al d\u00eda<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_133\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_133\" ><br><\/li><li id=\"field_1_109\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_109\" ><label class='gfield_label gform-field-label' >\u00bfCu\u00e1l fue el grado de intensidad de estos s\u00edntomas?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_109'>\n\t\t\t<li class='gchoice gchoice_1_109_0'>\n\t\t\t\t<input name='input_109' type='radio' value='5'  id='choice_1_109_0'    \/>\n\t\t\t\t<label for='choice_1_109_0' id='label_1_109_0' class='gform-field-label gform-field-label--type-inline'>Muy baja<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_109_1'>\n\t\t\t\t<input name='input_109' type='radio' value='4'  id='choice_1_109_1'    \/>\n\t\t\t\t<label for='choice_1_109_1' id='label_1_109_1' class='gform-field-label gform-field-label--type-inline'>Baja<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_109_2'>\n\t\t\t\t<input name='input_109' type='radio' value='3'  id='choice_1_109_2'    \/>\n\t\t\t\t<label for='choice_1_109_2' id='label_1_109_2' class='gform-field-label gform-field-label--type-inline'>Relativamente intensa<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_109_3'>\n\t\t\t\t<input name='input_109' type='radio' value='2'  id='choice_1_109_3'    \/>\n\t\t\t\t<label for='choice_1_109_3' id='label_1_109_3' class='gform-field-label gform-field-label--type-inline'>Intensa<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_109_4'>\n\t\t\t\t<input name='input_109' type='radio' value='1'  id='choice_1_109_4'    \/>\n\t\t\t\t<label for='choice_1_109_4' id='label_1_109_4' class='gform-field-label gform-field-label--type-inline'>Extremadamente intensa<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_110\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_110\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_110'>surdosage ok<\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_1_110' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_111\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_111\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_111'>surdosage ok2<\/label><div class='ginput_container ginput_container_text'><input name='input_111' id='input_1_111' type='text' value='OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_112\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_112\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_112'>surdosage pas ok<\/label><div class='ginput_container ginput_container_text'><input name='input_112' id='input_1_112' type='text' value='PAS OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_12\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_12\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_12'>Surdosage<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='PAS OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_48\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_48\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_48'>SEVRAGE<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_1_48' type='text' value='PAS OK' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_69\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_69\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_69'>Surdosage_propo<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_1_69' type='text' value='49' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_70\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_70\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_70'>SEVRAGE_propo<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_1_70' type='text' value='51' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_71\" class=\"gfield gfield--type-number gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_1_71\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_71'>Nombre<\/label><div class='ginput_container ginput_container_number'><input name='input_71' id='input_1_71' type='text' step='any'   value='' class='medium'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_115' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Anterior'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_115' class='gform_next_button gform-theme-button button' value='Siguiente'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"7\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"7\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_7' class='gform_page' data-js='page-field-id-115' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_116\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_116\" ><h2 class=\"gsection_title\">Efectos secundarios<\/h2><\/li><li id=\"field_1_135\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_135\" ><label class='gfield_label gform-field-label' >Durante los \u00faltimos 7 d\u00edas, \u00bfha experimentado alg\u00fan efecto secundario relacionado con el tratamiento?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_135'> Por ejemplo: estre\u00f1imiento, retenci\u00f3n urinaria, aumento de la sudoraci\u00f3n, insomnio o dificultad para conciliar el sue\u00f1o, deterioro de la funci\u00f3n sexual, alteraci\u00f3n menstrual, fatiga, dolores musculares, reacciones adversas, mareos, falta de deseo sexual, dificultades para tener una erecci\u00f3n satisfactoria, dificultades para tener un orgasmo.<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_135'>\n\t\t\t<li class='gchoice gchoice_1_135_0'>\n\t\t\t\t<input name='input_135' type='radio' value='0'  id='choice_1_135_0'    \/>\n\t\t\t\t<label for='choice_1_135_0' id='label_1_135_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_135_1'>\n\t\t\t\t<input name='input_135' type='radio' value='10'  id='choice_1_135_1'    \/>\n\t\t\t\t<label for='choice_1_135_1' id='label_1_135_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_136\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_136\" ><br><\/li><li id=\"field_1_121\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_121\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfCu\u00e1l de los siguientes efectos adversos ha sentido?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_121'><li class='gchoice gchoice_1_121_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.1' type='checkbox'  value='Constipation'  id='choice_1_121_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_1' id='label_1_121_1' class='gform-field-label gform-field-label--type-inline'>Estre\u00f1imiento<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.2' type='checkbox'  value='Re\u0301tention urinaire'  id='choice_1_121_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_2' id='label_1_121_2' class='gform-field-label gform-field-label--type-inline'>Retenci\u00f3n urinaria<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.3' type='checkbox'  value='Transpiration accrue'  id='choice_1_121_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_3' id='label_1_121_3' class='gform-field-label gform-field-label--type-inline'>Aumento de la sudoraci\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.4' type='checkbox'  value='Insomnie ou difficulte\u0301s a\u0300 s\u2019endormir'  id='choice_1_121_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_4' id='label_1_121_4' class='gform-field-label gform-field-label--type-inline'>Insomnio o dificultades para conciliar el sue\u00f1o<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.5' type='checkbox'  value='Alte\u0301ration de la fonction sexuelle'  id='choice_1_121_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_5' id='label_1_121_5' class='gform-field-label gform-field-label--type-inline'>Deterioro de la funci\u00f3n sexual<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.6' type='checkbox'  value='Alte\u0301ration menstruelle'  id='choice_1_121_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_6' id='label_1_121_6' class='gform-field-label gform-field-label--type-inline'>Alteraci\u00f3n menstrual<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.7' type='checkbox'  value='Fatigue'  id='choice_1_121_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_7' id='label_1_121_7' class='gform-field-label gform-field-label--type-inline'>Fatiga<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.8' type='checkbox'  value='Douleur musculaire ou courbatures'  id='choice_1_121_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_8' id='label_1_121_8' class='gform-field-label gform-field-label--type-inline'>Dolor muscular o agujetas<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.9' type='checkbox'  value='Effets inde\u0301sirables'  id='choice_1_121_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_9' id='label_1_121_9' class='gform-field-label gform-field-label--type-inline'>Efectos adversos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.11' type='checkbox'  value='Vertiges'  id='choice_1_121_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_11' id='label_1_121_11' class='gform-field-label gform-field-label--type-inline'>Mareos o v\u00e9rtigo<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.12' type='checkbox'  value='Manque de de\u0301sir sexuel'  id='choice_1_121_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_12' id='label_1_121_12' class='gform-field-label gform-field-label--type-inline'>Falta de deseo sexual<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.13' type='checkbox'  value='Difficulte\u0301s a\u0300 avoir une e\u0301rection satisfaisante'  id='choice_1_121_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_13' id='label_1_121_13' class='gform-field-label gform-field-label--type-inline'>Dificultad para tener una erecci\u00f3n satisfactoria<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_121_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.14' type='checkbox'  value='Difficulte\u0301s a\u0300 avoir un orgasme'  id='choice_1_121_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_121_14' id='label_1_121_14' class='gform-field-label gform-field-label--type-inline'>Dificultad para tener un orgasmo<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_137' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Anterior'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_137' class='gform_next_button gform-theme-button button' value='Siguiente'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"8\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"8\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_8' class='gform_page' data-js='page-field-id-137' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_138\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_138\" ><h2 class=\"gsection_title\">Su opini\u00f3n sobre su dosis<\/h2><\/li><li id=\"field_1_117\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_117\" ><label class='gfield_label gform-field-label' >La dosis de su tratamiento de sustituci\u00f3n le parece:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_117'>\n\t\t\t<li class='gchoice gchoice_1_117_0'>\n\t\t\t\t<input name='input_117' type='radio' value='1'  id='choice_1_117_0'    \/>\n\t\t\t\t<label for='choice_1_117_0' id='label_1_117_0' class='gform-field-label gform-field-label--type-inline'>Totalmente inadecuado<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_117_1'>\n\t\t\t\t<input name='input_117' type='radio' value='2'  id='choice_1_117_1'    \/>\n\t\t\t\t<label for='choice_1_117_1' id='label_1_117_1' class='gform-field-label gform-field-label--type-inline'>Inadecuada<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_117_2'>\n\t\t\t\t<input name='input_117' type='radio' value='3'  id='choice_1_117_2'    \/>\n\t\t\t\t<label for='choice_1_117_2' id='label_1_117_2' class='gform-field-label gform-field-label--type-inline'>Ni adecuada ni inadecuada<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_117_3'>\n\t\t\t\t<input name='input_117' type='radio' value='4'  id='choice_1_117_3'    \/>\n\t\t\t\t<label for='choice_1_117_3' id='label_1_117_3' class='gform-field-label gform-field-label--type-inline'>Adecuada<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_117_4'>\n\t\t\t\t<input name='input_117' type='radio' value='5'  id='choice_1_117_4'    \/>\n\t\t\t\t<label for='choice_1_117_4' id='label_1_117_4' class='gform-field-label gform-field-label--type-inline'>Perfectamente adecuada<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_134\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_134\" ><br><\/li><li id=\"field_1_118\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_118\" ><label class='gfield_label gform-field-label' >Usted piensa que su tratamiento deber\u00eda :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_118'>\n\t\t\t<li class='gchoice gchoice_1_118_0'>\n\t\t\t\t<input name='input_118' type='radio' value='\u00eatre augment\u00e9'  id='choice_1_118_0'    \/>\n\t\t\t\t<label for='choice_1_118_0' id='label_1_118_0' class='gform-field-label gform-field-label--type-inline'>aumentarse<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_118_1'>\n\t\t\t\t<input name='input_118' type='radio' value='\u00eatre diminu\u00e9'  id='choice_1_118_1'    \/>\n\t\t\t\t<label for='choice_1_118_1' id='label_1_118_1' class='gform-field-label gform-field-label--type-inline'>disminuirse<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_118_2'>\n\t\t\t\t<input name='input_118' type='radio' value='\u00eatre maintenu'  id='choice_1_118_2'    \/>\n\t\t\t\t<label for='choice_1_118_2' id='label_1_118_2' class='gform-field-label gform-field-label--type-inline'>mantenerse<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_139\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_139\" ><br><\/li><li id=\"field_1_142\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_142\" ><label class='gfield_label gform-field-label' >\u00bfLe gustar\u00eda recibir una copia por correo electr\u00f3nico de los resultados de esta evaluaci\u00f3n?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_142'>\n\t\t\t<li class='gchoice gchoice_1_142_0'>\n\t\t\t\t<input name='input_142' type='radio' value='Oui'  id='choice_1_142_0'    \/>\n\t\t\t\t<label for='choice_1_142_0' id='label_1_142_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_142_1'>\n\t\t\t\t<input name='input_142' type='radio' value='Non'  id='choice_1_142_1'    \/>\n\t\t\t\t<label for='choice_1_142_1' id='label_1_142_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_143\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_143\" ><label class='gfield_label gform-field-label' for='input_1_143'>E-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_143' id='input_1_143' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_144\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_144\" ><label class='gfield_label gform-field-label' for='input_1_144'>Email<\/label><div class='ginput_container'><input name='input_144' id='input_1_144' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_144'>Este campo es un campo de validaci\u00f3n y debe quedar sin cambios.<\/div><\/li><\/ul><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_1' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Anterior'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Terminar'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='WyJbXSIsIjAwMGQ3MWMyNWEwY2Q2MjlhMmQ3MjJmNGNiNDU2NTY1Il0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='2' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/div><\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 1, 'https:\/\/opiatest.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_1').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_1');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_1').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_1').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_1').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_1').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_1').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_1').val();gformInitSpinner( 1, 'https:\/\/opiatest.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [1, current_page]);window['gf_submitting_1'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_1').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_1').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [1]);window['gf_submitting_1'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_1').text());}else{jQuery('#gform_1').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"1\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);                if (event && event.defaultPrevented) {                return;         }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_1\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_1\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = 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