{"id":51288,"date":"2025-08-12T11:11:41","date_gmt":"2025-08-12T09:11:41","guid":{"rendered":"https:\/\/dev.institutchiaribcn.com\/test-enfermedad-filum\/"},"modified":"2026-01-19T12:42:12","modified_gmt":"2026-01-19T11:42:12","slug":"test-filum-disease","status":"publish","type":"page","link":"https:\/\/institutchiaribcn.com\/en\/test-filum-disease\/","title":{"rendered":"Test Institut Chiari"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"51288\" class=\"elementor elementor-51288 elementor-48668\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-261dbdf e-flex e-con-boxed e-con e-parent\" data-id=\"261dbdf\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-f6cd230 e-con-full e-flex e-con e-child\" data-id=\"f6cd230\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-9446ae8 elementor-widget elementor-widget-heading\" data-id=\"9446ae8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">All you need to know about chiari, syringomyelia and scoliosis<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-207b628 elementor-widget elementor-widget-heading\" data-id=\"207b628\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Diagnostic Probability Test \u2013 Filum Disease<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-3e9ce7d e-flex e-con-boxed e-con e-parent\" data-id=\"3e9ce7d\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-abcae57 elementor-widget elementor-widget-shortcode\" data-id=\"abcae57\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Test Filum<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/en\/wp-json\/wp\/v2\/pages\/51288' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_25\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_25'>Facebook<\/label><div class='ginput_container'><input name='input_25' id='input_1_25' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_25'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_1_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_1'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_1_1' type='text' value='' class='large'    placeholder='Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>E-mail address<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_10' id='input_1_10' type='email' value='' class='large'   placeholder='E-mail' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>Sex<\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_1_11' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Sex<\/option><option value='Femenino' >Female<\/option><option value='Masculino' >Male<\/option><\/select><\/div><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>Age<\/label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_1_12' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Age<\/option><option value='Menor de 16 a\u00f1os' >Under 16 years<\/option><option value='Entre 16 y 30 a\u00f1os' >Between 16 and 30 years<\/option><option value='Entre 31 y 45 a\u00f1os' >Between 31 and 45 years<\/option><option value='Entre 46 y 59 a\u00f1os' >Between 46 and 59 years<\/option><option value='M\u00e1s de 60 a\u00f1os' >More than 60 years<\/option><\/select><\/div><\/div><fieldset id=\"field_1_21\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >* It is imperative to tick this box.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_21.1' id='input_1_21_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_21_1' ><a target=\u201d_blank\u201d href=\"https:\/\/institutchiaribcn.com\/en\/legal-notice\/\">I accept the legal conditions and consent expressly to the treatment of my personal data according to the EU regulation 2016\/679.<\/a><\/label><input type='hidden' name='input_21.2' value='&lt;a target=\u201d_blank\u201d href=&quot;https:\/\/institutchiaribcn.com\/en\/legal-notice\/&quot;&gt;I accept the legal conditions and consent expressly to the treatment of my personal data according to the EU regulation 2016\/679.&lt;\/a&gt;' class='gform_hidden' \/><input type='hidden' name='input_21.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_1_4\" class=\"gfield gfield--type-html gfield--input-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\"  ><div class=\"icseb-section\">\r\n    <h2>Personal details<\/h2>\r\n<\/div>\r\n<p class=\"icseb-section-text\"><strong>Do you have any of these diagnoses?<\/strong><\/p><\/div><fieldset id=\"field_1_6\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Antecedentes personales<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_6'><div class='gchoice gchoice_1_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='200'  id='choice_1_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_1' id='label_1_6_1' class='gform-field-label gform-field-label--type-inline'>Arnold-Chiari Syndrome Type I.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='600'  id='choice_1_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_2' id='label_1_6_2' class='gform-field-label gform-field-label--type-inline'>Idiopathic Syringomyelia.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_6_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.3' type='checkbox'  value='200'  id='choice_1_6_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_3' id='label_1_6_3' class='gform-field-label gform-field-label--type-inline'>Basilar Invagination, Odontoid Retroflexion, Brainstem Kinking, nocturnal enuresis.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_6_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.4' type='checkbox'  value='100'  id='choice_1_6_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_4' id='label_1_6_4' class='gform-field-label gform-field-label--type-inline'>Idiopathic Scoliosis or Kyphosis.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_6_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.5' type='checkbox'  value='10'  id='choice_1_6_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_5' id='label_1_6_5' class='gform-field-label gform-field-label--type-inline'>Disc protrusions or herniations.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_6_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.6' type='checkbox'  value='10'  id='choice_1_6_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_6' id='label_1_6_6' class='gform-field-label gform-field-label--type-inline'>A bent back.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_6_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.7' type='checkbox'  value='0'  id='choice_1_6_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_7' id='label_1_6_7' class='gform-field-label gform-field-label--type-inline'>Other diagnoses.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_7\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'>txtOtrosDiagnosticos<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_7' id='input_1_7' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_19\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"icseb-section\">\r\n    <h2>Family history<\/h2>\r\n<\/div>\r\n<p class=\"icseb-section-text\"><strong>Are there any of these antecedents in your mother\u2019s or father\u2019s a relative\u2019s history?<\/strong><\/p><\/div><fieldset id=\"field_1_20\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Antecedentes familiares<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_20'><div class='gchoice gchoice_1_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='4'  id='choice_1_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_1' id='label_1_20_1' class='gform-field-label gform-field-label--type-inline'>Arnold-Chiari Syndrome Type I.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='4'  id='choice_1_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_2' id='label_1_20_2' class='gform-field-label gform-field-label--type-inline'>Idiopathic Syringomyelia.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='4'  id='choice_1_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_3' id='label_1_20_3' class='gform-field-label gform-field-label--type-inline'>Idiopathic Scoliosis or Kyphosis.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_13\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"icseb-section\">\r\n    <h2>Symptoms<\/h2>\r\n<\/div>\r\n<p class=\"icseb-section-text\"><strong>Do you experience pain in one or more of any of these body parts?<\/strong><\/p><\/div><fieldset id=\"field_1_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >S\u00edntomas<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_16'><div class='gchoice gchoice_1_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='2'  id='choice_1_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_1' id='label_1_16_1' class='gform-field-label gform-field-label--type-inline'>Head.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='2'  id='choice_1_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_2' id='label_1_16_2' class='gform-field-label gform-field-label--type-inline'>Back of the neck.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='2'  id='choice_1_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_3' id='label_1_16_3' class='gform-field-label gform-field-label--type-inline'>Neck.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='1'  id='choice_1_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_4' id='label_1_16_4' class='gform-field-label gform-field-label--type-inline'>Upper back.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='1'  id='choice_1_16_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_5' id='label_1_16_5' class='gform-field-label gform-field-label--type-inline'>Lower back.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='2'  id='choice_1_16_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_6' id='label_1_16_6' class='gform-field-label gform-field-label--type-inline'>Tailbone or coccyx.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.7' type='checkbox'  value='1'  id='choice_1_16_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_7' id='label_1_16_7' class='gform-field-label gform-field-label--type-inline'>Upper extremities (partially or entirely).<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_16_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.8' type='checkbox'  value='1'  id='choice_1_16_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_16_8' id='label_1_16_8' class='gform-field-label gform-field-label--type-inline'>Lower extremities (partially or entirely).<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_15\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"icseb-section-text\"><strong>Do you have any of the following symptoms?<\/strong><\/p><\/div><fieldset id=\"field_1_14\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >S\u00edntomas2<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_14'><div class='gchoice gchoice_1_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='2'  id='choice_1_14_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_1' id='label_1_14_1' class='gform-field-label gform-field-label--type-inline'>Tingling or numbness anywhere in the body.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='1'  id='choice_1_14_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_2' id='label_1_14_2' class='gform-field-label gform-field-label--type-inline'>I have nausea and\/or vertigo.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_14_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.3' type='checkbox'  value='2'  id='choice_1_14_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_3' id='label_1_14_3' class='gform-field-label gform-field-label--type-inline'>I have vertigo.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_14_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.4' type='checkbox'  value='2'  id='choice_1_14_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_4' id='label_1_14_4' class='gform-field-label gform-field-label--type-inline'>I have a sensation of instability when I am standing or walking.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_14_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.5' type='checkbox'  value='2'  id='choice_1_14_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_5' id='label_1_14_5' class='gform-field-label gform-field-label--type-inline'>I have difficulties swallowing fluids or solids or the sensation of having a lump in the throat.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_14_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.6' type='checkbox'  value='2'  id='choice_1_14_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_6' id='label_1_14_6' class='gform-field-label gform-field-label--type-inline'>I faint.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_14_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.7' type='checkbox'  value='1'  id='choice_1_14_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_7' id='label_1_14_7' class='gform-field-label gform-field-label--type-inline'>I suffer with insomnia.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_14_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.8' type='checkbox'  value='2'  id='choice_1_14_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_8' id='label_1_14_8' class='gform-field-label gform-field-label--type-inline'>I tire easily or am always tired.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_14_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.9' type='checkbox'  value='1'  id='choice_1_14_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_9' id='label_1_14_9' class='gform-field-label gform-field-label--type-inline'>I have a gait alteration\/limitation.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_14_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.11' type='checkbox'  value='2'  id='choice_1_14_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_11' id='label_1_14_11' class='gform-field-label gform-field-label--type-inline'>I have a skin area that is little or insensitive to touch or pain.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_14_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.12' type='checkbox'  value='4'  id='choice_1_14_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_14_12' id='label_1_14_12' class='gform-field-label gform-field-label--type-inline'>I have a skin area that is little or insensitive to hear or cold.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_17\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"icseb-section-text\"><strong>Do you have any difficulty with<\/strong><\/p><\/div><fieldset id=\"field_1_18\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Dificultades<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_18'><div class='gchoice gchoice_1_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='2'  id='choice_1_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_1' id='label_1_18_1' class='gform-field-label gform-field-label--type-inline'>Attention and\/or concentration.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='2'  id='choice_1_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_2' id='label_1_18_2' class='gform-field-label gform-field-label--type-inline'>Memory.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='1'  id='choice_1_18_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_18_3' id='label_1_18_3' class='gform-field-label gform-field-label--type-inline'>Speech.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_8\" class=\"gfield gfield--type-number gfield--input-type-number gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_8'>N\u00famero<\/label><div class='ginput_container ginput_container_number'><input name='input_8' id='input_1_8' type='text' step='any'   value='' class='large gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_22\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_22'>Valoracion<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_1_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_24\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_24'>Email destinatario Chiari<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_1_24' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Get result'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input 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