{"id":3193,"date":"2021-01-03T03:36:36","date_gmt":"2021-01-03T03:36:36","guid":{"rendered":"https:\/\/screening.mhanational.org\/?post_type=screen&#038;p=3193"},"modified":"2025-07-18T16:13:24","modified_gmt":"2025-07-18T20:13:24","slug":"test-de-depresion","status":"publish","type":"screen","link":"https:\/\/screening.mhanational.org\/es\/screening-tools\/test-de-depresion\/","title":{"rendered":"Prueba de depresi\u00f3n"},"content":{"rendered":"<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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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_17' style='display:none'>\n                        <div class='gform_heading'>\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_17'  class='clearfix' action='\/es\/wp-json\/wp\/v2\/screen\/3193' data-formid='17' novalidate><ol class=\"screen-progress-bar clearfix step-1-of-3\">\n\t\t\t\t\t<li class=\"step-1\"><span>Preguntas<br \/>de la Prueba<\/span><\/li>\n\t\t\t\t\t<li class=\"step-2\"><span>Preguntas<br \/>Opcionales<\/span><\/li>\n\t\t\t\t\t<li class=\"step-3\"><span>Sus<br \/>Resultados<\/span><\/li>\n\t\t\t\t<\/ol>\n                        <div class='gform-body gform_body'><div id='gform_page_17_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_17' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_17_84\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_84'>Comments<\/label><div class='gfield_description' id='gfield_description_17_84'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_84' id='input_17_84' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_17_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_above field_validation_below gfield_visibility_visible\"  ><p>Durante las \u00faltimas 2 semanas, \u00bfcon qu\u00e9 frecuencia ha sentido molestias por los siguientes problemas?<\/p>\n\n<p>Todos los campos son obligatorios.<\/p><\/div><div id=\"field_17_38\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_38' id='input_17_38' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_17_39\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><input name=\"input_39\" id=\"input_17_39\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"3193\"><\/div><div id=\"field_17_40\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><input name=\"input_40\" id=\"input_17_40\" type=\"hidden\" class=\"gform_hidden\" aria-invalid=\"false\" value=\"1065b15f1fb646497a4b06db21f9fba2\"><\/div><div id=\"field_17_41\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_41' id='input_17_41' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_17_55\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_55' id='input_17_55' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_17_57\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_57' id='input_17_57' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_17_58\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_58' id='input_17_58' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_17_59\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_59' id='input_17_59' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_17_79\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_79' id='input_17_79' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_17_83\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_83' id='input_17_83' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='lang--es' \/><\/div><\/div><fieldset id=\"field_17_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. Tener poco inter\u00e9s o placer en hacer las cosas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_5'>\n\t\t\t<div class='gchoice gchoice_17_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='0'  id='choice_17_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_5_0' id='label_17_5_0' class='gform-field-label gform-field-label--type-inline'>Nunca<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='1'  id='choice_17_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_5_1' id='label_17_5_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_5_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='2'  id='choice_17_5_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_5_2' id='label_17_5_2' class='gform-field-label gform-field-label--type-inline'>M\u00e1s de la mitad de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_5_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='3'  id='choice_17_5_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_5_3' id='label_17_5_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_17_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. Sentirse desanimado\/a, deprimido\/a, o sin esperanza<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_47'>\n\t\t\t<div class='gchoice gchoice_17_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='0'  id='choice_17_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_47_0' id='label_17_47_0' class='gform-field-label gform-field-label--type-inline'>Nunca<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='1'  id='choice_17_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_47_1' id='label_17_47_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_47_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='2'  id='choice_17_47_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_47_2' id='label_17_47_2' class='gform-field-label gform-field-label--type-inline'>M\u00e1s de la mitad de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_47_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='3'  id='choice_17_47_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_47_3' id='label_17_47_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_17_48\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. Con problemas en dormirse o en mantenerse dormido\/a, o en dormir demasiado<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_48'>\n\t\t\t<div class='gchoice gchoice_17_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='0'  id='choice_17_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_48_0' id='label_17_48_0' class='gform-field-label gform-field-label--type-inline'>Nunca<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='1'  id='choice_17_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_48_1' id='label_17_48_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_48_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='2'  id='choice_17_48_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_48_2' id='label_17_48_2' class='gform-field-label gform-field-label--type-inline'>M\u00e1s de la mitad de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_48_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='3'  id='choice_17_48_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_48_3' id='label_17_48_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_17_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Sentirse cansado\/a o tener poca energ\u00eda<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_49'>\n\t\t\t<div class='gchoice gchoice_17_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='0'  id='choice_17_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_49_0' id='label_17_49_0' class='gform-field-label gform-field-label--type-inline'>Nunca<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='1'  id='choice_17_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_49_1' id='label_17_49_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_49_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='2'  id='choice_17_49_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_49_2' id='label_17_49_2' class='gform-field-label gform-field-label--type-inline'>M\u00e1s de la mitad de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_49_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='3'  id='choice_17_49_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_49_3' id='label_17_49_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_17_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5. Tener poco apetito o comer en exceso<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_50'>\n\t\t\t<div class='gchoice gchoice_17_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='0'  id='choice_17_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_50_0' id='label_17_50_0' class='gform-field-label gform-field-label--type-inline'>Nunca<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='1'  id='choice_17_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_50_1' id='label_17_50_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_50_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='2'  id='choice_17_50_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_50_2' id='label_17_50_2' class='gform-field-label gform-field-label--type-inline'>M\u00e1s de la mitad de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_50_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='3'  id='choice_17_50_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_50_3' id='label_17_50_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_17_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Sentir falta de amor propio - o que sea un fracaso o que decepcionara a si mismo\/a su familia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_51'>\n\t\t\t<div class='gchoice gchoice_17_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='0'  id='choice_17_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_51_0' id='label_17_51_0' class='gform-field-label gform-field-label--type-inline'>Nunca<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='1'  id='choice_17_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_51_1' id='label_17_51_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_51_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='2'  id='choice_17_51_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_51_2' id='label_17_51_2' class='gform-field-label gform-field-label--type-inline'>M\u00e1s de la mitad de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_51_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='3'  id='choice_17_51_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_51_3' id='label_17_51_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_17_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Tener dificultad para concentrarse en cosas tales como leer el peri\u00f3dico o mirar la televisi\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_52'>\n\t\t\t<div class='gchoice gchoice_17_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='0'  id='choice_17_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_52_0' id='label_17_52_0' class='gform-field-label gform-field-label--type-inline'>Nunca<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='1'  id='choice_17_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_52_1' id='label_17_52_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_52_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='2'  id='choice_17_52_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_52_2' id='label_17_52_2' class='gform-field-label gform-field-label--type-inline'>M\u00e1s de la mitad de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_52_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='3'  id='choice_17_52_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_52_3' id='label_17_52_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_17_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >8. Se mueve o habla tan lentamente que otra gente se podr\u00eda dar cuenta<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_17_53'>o de la contrario, est\u00e1 tan agitado\/a o inquieto\/a que se mueve mucho m\u00e1s de lo acostumbrado<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_53'>\n\t\t\t<div class='gchoice gchoice_17_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='0'  id='choice_17_53_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_17_53\"   \/>\n\t\t\t\t\t<label for='choice_17_53_0' id='label_17_53_0' class='gform-field-label gform-field-label--type-inline'>Nunca<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='1'  id='choice_17_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_53_1' id='label_17_53_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_53_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='2'  id='choice_17_53_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_53_2' id='label_17_53_2' class='gform-field-label gform-field-label--type-inline'>M\u00e1s de la mitad de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_53_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='3'  id='choice_17_53_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_53_3' id='label_17_53_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_17_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question alert gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >9. Se la han ocurrido pensamientos de que ser\u00eda mejor estar muerto\/a o de que har\u00eda da\u00f1o de alguna manera<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_13'>\n\t\t\t<div class='gchoice gchoice_17_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='0'  id='choice_17_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_13_0' id='label_17_13_0' class='gform-field-label gform-field-label--type-inline'>Nunca<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='1'  id='choice_17_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_13_1' id='label_17_13_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='2'  id='choice_17_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_13_2' id='label_17_13_2' class='gform-field-label gform-field-label--type-inline'>M\u00e1s de la mitad de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_13_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='3'  id='choice_17_13_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_13_3' id='label_17_13_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_17_16\" class=\"gfield gfield--type-html gfield--input-type-html warning gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >\u00bfEst\u00e1 en crisis? En los Estados Unidos, puede llamar o mandar text a <a href=\"tel:+1-888-628-9454\">1-888-628-9454<\/a> para conectarse directamente con la L\u00ednea de Prevenci\u00f3n del Suicidio y Crisis.<\/div><fieldset id=\"field_17_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio question gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >10. Si usted se identific\u00f3 con cualquier problema en este cuestionario, \u00bfqu\u00e9 tan dif\u00edcil se la ha hecho cumplir con su trabajo, atender su casa, o relacionarse con otras personas debido a estos problemas?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_14'>\n\t\t\t<div class='gchoice gchoice_17_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Nada en absoluto'  id='choice_17_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_14_0' id='label_17_14_0' class='gform-field-label gform-field-label--type-inline'>Nada en absoluto<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Algo dif\u00edcil'  id='choice_17_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_14_1' id='label_17_14_1' class='gform-field-label gform-field-label--type-inline'>Algo dif\u00edcil<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_14_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Muy dif\u00edcil'  id='choice_17_14_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_14_2' id='label_17_14_2' class='gform-field-label gform-field-label--type-inline'>Muy dif\u00edcil<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_14_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Extremadamente dif\u00edcil'  id='choice_17_14_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_14_3' id='label_17_14_3' class='gform-field-label gform-field-label--type-inline'>Extremadamente dif\u00edcil<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_17_17' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_2' class='gform_page demographics' data-js='page-field-id-17' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_17_18\" 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_above field_validation_below gfield_visibility_visible\"  ><p>Antes de ver sus resultados, por favor tome unos momentos para responder a las siguientes preguntas <strong>opcionales<\/strong>. Si no se siente c\u00f3modo compartiendo alguna o toda la informaci\u00f3n, puede hacer clic en \"ver sus resultados\" en seguida. De otra manera, sus respuestas nos ayudar\u00e1n a entender c\u00f3mo podemos lograr nuestra misi\u00f3n de una mejor manera. No se preocupe; nosotros no podremos identificarle en base a esta informaci\u00f3n.<\/p>\n\n<p>Sus respuestas nos ayudar\u00e1n a proveer mejor apoyo para los dem\u00e1s que tomen esta prueba. Sus respuestas son totalmente an\u00f3nimas. Puede responder solamente a las preguntas que quiera. Tambi\u00e9n puede ir al fondo de la p\u00e1gina y hacer clic en \"ver sus resultados\" para obtener sus resultados sin responder a estas preguntas.<\/p><\/div><div id=\"field_17_66\" 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_above field_validation_below gfield_visibility_visible\"  ><hr \/><\/div><fieldset id=\"field_17_67\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfEst\u00e1 tomando este test por s\u00ed mismo o por otra persona?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_67'>\n\t\t\t<div class='gchoice gchoice_17_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Por m\u00ed mismo'  id='choice_17_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_67_0' id='label_17_67_0' class='gform-field-label gform-field-label--type-inline'>Por m\u00ed mismo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Por otra persona'  id='choice_17_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_67_1' id='label_17_67_1' class='gform-field-label gform-field-label--type-inline'>Por otra persona<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_17_68\" 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_above field_validation_below gfield_visibility_visible\"  >Si est\u00e1 tomando este test para otra persona, <strong>por favor use los datos de esa persona<\/strong> para las siguientes preguntas, o d\u00e9jelas en blanco si no sabe la respuesta. Recuerde, <em>estas preguntas son opcionales<\/em>.<\/div><div id=\"field_17_42\" class=\"gfield gfield--type-html gfield--input-type-html section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2>Acerca de usted<\/h2><\/div><div id=\"field_17_19\" class=\"gfield gfield--type-select gfield--input-type-select optional taxonomy field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_19'>Edad<\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_17_19' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='8-10' >8-10<\/option><option value='11-13' >11-13<\/option><option value='14-15' >14-15<\/option><option value='16-17' >16-17<\/option><option value='18-24' >18-24<\/option><option value='25-34' >25-34<\/option><option value='35-44' >35-44<\/option><option value='45-54' >45-54<\/option><option value='55-64' >55-64<\/option><option value='65+' >65+<\/option><\/select><\/div><\/div><fieldset id=\"field_17_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >G\u00e9nero<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_46'>\n\t\t\t<div class='gchoice gchoice_17_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Femenina'  id='choice_17_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_46_0' id='label_17_46_0' class='gform-field-label gform-field-label--type-inline'>Femenina<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Masculino'  id='choice_17_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_46_1' id='label_17_46_1' class='gform-field-label gform-field-label--type-inline'>Masculino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_46_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='No binario'  id='choice_17_46_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_46_2' id='label_17_46_2' class='gform-field-label gform-field-label--type-inline'>No binario<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_17_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfUsted se identifica como transg\u00e9nera\/o?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_80'>\n\t\t\t<div class='gchoice gchoice_17_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='S\u00ed'  id='choice_17_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_80_0' id='label_17_80_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='No'  id='choice_17_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_80_1' id='label_17_80_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_17_56\" class=\"gfield gfield--type-text gfield--input-type-text optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_56'>\u00bfC\u00f3mo describir\u00eda su g\u00e9nero?<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_17_56' type='text' value='' class='small'    placeholder='\u00c9ntre g\u00e9nero...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_17_22\" class=\"gfield gfield--type-select gfield--input-type-select optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_22'>Raza\/origen \u00e9tnico<\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_17_22' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Hispano\/a o latino\/a' >Hispano\/a o latino\/a<\/option><option value='\u00c1rabe o del norte de \u00c1frica' >\u00c1rabe o del norte de \u00c1frica<\/option><option value='Asi\u00e1tico\/a' >Asi\u00e1tico\/a<\/option><option value='Blanco\/a (no hispano\/a)' >Blanco\/a (no hispano\/a)<\/option><option value='Ind\u00edgeno\/a de las Am\u00e9ricas o nativo\/a de Alaska' >Ind\u00edgeno\/a de las Am\u00e9ricas o nativo\/a de Alaska<\/option><option value='Nativo\/a de Haw\u00e1i u otro isle\u00f1o del Pac\u00edfico' >Nativo\/a de Haw\u00e1i u otro isle\u00f1o del Pac\u00edfico<\/option><option value='Negro\/a o afroamericano\/a (no hispano)' >Negro\/a o afroamericano\/a (no hispano)<\/option><option value='M\u00e1s de uno de los anteriores' >M\u00e1s de uno de los anteriores<\/option><option value='Otro' >Otro<\/option><\/select><\/div><\/div><div id=\"field_17_54\" class=\"gfield gfield--type-select gfield--input-type-select optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_54'>Si es de origen Hispano, Latino o Espa\u00f1ol, favor marque lo que le corresponda<\/label><div class='ginput_container ginput_container_select'><select name='input_54' id='input_17_54' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Mexicano, mexicano americano o chicano' >Mexicano, mexicano americano o chicano<\/option><option value='Centroamericano' >Centroamericano<\/option><option value='Sudamericano' >Sudamericano<\/option><option value='Caribe\u00f1o' >Caribe\u00f1o<\/option><option value='Espa\u00f1ol' >Espa\u00f1ol<\/option><option value='Otro origen hisp\u00e1nico, latino, o espa\u00f1ol' >Otro origen hisp\u00e1nico, latino, o espa\u00f1ol<\/option><\/select><\/div><\/div><div id=\"field_17_23\" class=\"gfield gfield--type-select gfield--input-type-select optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_23'>Ingreso anual de su hogar (USD)<\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_17_23' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Menos de $20,000' >Menos de $20,000<\/option><option value='$20,000 - $39,999' >$20,000 - $39,999<\/option><option value='$40,000 - $59,999' >$40,000 - $59,999<\/option><option value='$60,000 - $79,999' >$60,000 - $79,999<\/option><option value='$80,000 - $99,999' >$80,000 - $99,999<\/option><option value='$100,000 - $149,999' >$100,000 - $149,999<\/option><option value='$150,000+' >$150,000+<\/option><\/select><\/div><\/div><fieldset id=\"field_17_69\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfVive en los Estados Unidos de Am\u00e9rica?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_69'>\n\t\t\t<div class='gchoice gchoice_17_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Vivo en los EEUU'  id='choice_17_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_69_0' id='label_17_69_0' class='gform-field-label gform-field-label--type-inline'>Vivo en los EEUU<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Vivo en otro pa\u00eds'  id='choice_17_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_69_1' id='label_17_69_1' class='gform-field-label gform-field-label--type-inline'>Vivo en otro pa\u00eds<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_17_32\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_32'>Estado<\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_17_32' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_17_36\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_36'>\u00bfEn qu\u00e9 pa\u00eds vive usted?<\/label><div class='ginput_container ginput_container_select'><select name='input_36' id='input_17_36' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Afganist\u00e1n' >Afganist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Angola' >Angola<\/option><option value='Argelia' >Argelia<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Banglad\u00e9s' >Banglad\u00e9s<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Belice' >Belice<\/option><option value='Ben\u00edn' >Ben\u00edn<\/option><option value='Bielorrusia' >Bielorrusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Botsuana' >Botsuana<\/option><option value='Brazil' >Brazil<\/option><option value='Brun\u00e9i' >Brun\u00e9i<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canad\u00e1' >Canad\u00e1<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Corea del Norte' >Corea del Norte<\/option><option value='Corea del Sur' >Corea del Sur<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='Eritrea' >Eritrea<\/option><option value='Escocia' >Escocia<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estonia' >Estonia<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Grecia' >Grecia<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guinea' >Guinea<\/option><option value='Holanda' >Holanda<\/option><option value='Honduras' >Honduras<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Inglaterra' >Inglaterra<\/option><option value='Irak' >Irak<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Irlanda' >Irlanda<\/option><option value='Islandia' >Islandia<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jordania' >Jordania<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Letonia' >Letonia<\/option><option value='Liberia' >Liberia<\/option><option value='Libia' >Libia<\/option><option value='Lituania' >Lituania<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malaui' >Malaui<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Moldavia' >Moldavia<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Mozambique' >Mozambique<\/option><option value='Namibia' >Namibia<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Noruega' >Noruega<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palestina' >Palestina<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica centroafricana' >Rep\u00fablica centroafricana<\/option><option value='Rep\u00fablica Checa' >Rep\u00fablica Checa<\/option><option value='Rep\u00fablica del Congo' >Rep\u00fablica del Congo<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Ruanda' >Ruanda<\/option><option value='Rumania' >Rumania<\/option><option value='Rusia' >Rusia<\/option><option value='Rusia' >Rusia<\/option><option value='Salvador' >Salvador<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Siria' >Siria<\/option><option value='Somalia' >Somalia<\/option><option value='Suazilandia' >Suazilandia<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Tailandia' >Tailandia<\/option><option value='Tanzania' >Tanzania<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabue' >Zimbabue<\/option><\/select><\/div><\/div><div id=\"field_17_34\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_34'>C\u00f3digo postal<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_17_34' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_17_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox optional traditional field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfCu\u00e1l de las siguientes poblaciones le describe a usted?<\/legend><div class='gfield_description' id='gfield_description_17_28'>Marque todas las que aplican.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_28'><div class='gchoice gchoice_17_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='Veterano\/a o militar activo\/a'  id='choice_17_28_1'   aria-describedby=\"gfield_description_17_28\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_17_28_1' id='label_17_28_1' class='gform-field-label gform-field-label--type-inline'>Veterano\/a o militar activo\/a<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='Cuidador\/a de una persona que vive con una enfermedad emocional o f\u00edsica'  id='choice_17_28_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_28_2' id='label_17_28_2' class='gform-field-label gform-field-label--type-inline'>Cuidador\/a de una persona que vive con una enfermedad emocional o f\u00edsica<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_28_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.3' type='checkbox'  value='LGBTQ+'  id='choice_17_28_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_28_3' id='label_17_28_3' class='gform-field-label gform-field-label--type-inline'>LGBTQ+<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_28_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.4' type='checkbox'  value='Estudiante'  id='choice_17_28_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_28_4' id='label_17_28_4' class='gform-field-label gform-field-label--type-inline'>Estudiante<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_28_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.5' type='checkbox'  value='Sobreviviente de trauma'  id='choice_17_28_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_28_5' id='label_17_28_5' class='gform-field-label gform-field-label--type-inline'>Sobreviviente de trauma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_28_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.6' type='checkbox'  value='Nueva madre\/padre o embarazada'  id='choice_17_28_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_28_6' id='label_17_28_6' class='gform-field-label gform-field-label--type-inline'>Nueva madre\/padre o embarazada<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_28_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.7' type='checkbox'  value='Trabajador de la salud'  id='choice_17_28_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_28_7' id='label_17_28_7' class='gform-field-label gform-field-label--type-inline'>Trabajador de la salud<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_17_70\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full traditional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfEst\u00e1 cuidando a alguien que tiene una enfermedad mental o f\u00edsica?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_70'>\n\t\t\t<div class='gchoice gchoice_17_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Enfermedad mental'  id='choice_17_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_70_0' id='label_17_70_0' class='gform-field-label gform-field-label--type-inline'>Enfermedad mental<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Enfermedad f\u00edsica'  id='choice_17_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_70_1' id='label_17_70_1' class='gform-field-label gform-field-label--type-inline'>Enfermedad f\u00edsica<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_70_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Enfermedades mentales y f\u00edsicas'  id='choice_17_70_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_70_2' id='label_17_70_2' class='gform-field-label gform-field-label--type-inline'>Enfermedades mentales y f\u00edsicas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_17_71\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_71'>\u00bfCu\u00e1l de estas opciones mejor describe su orientaci\u00f3n sexual?<\/label><div class='ginput_container ginput_container_select'><select name='input_71' id='input_17_71' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Lesbiana o gay' >Lesbiana o gay<\/option><option value='Bisexual' >Bisexual<\/option><option value='Queer' >Queer<\/option><option value='Pansexual' >Pansexual<\/option><option value='Asexual' >Asexual<\/option><option value='Heterosexual' >Heterosexual<\/option><option value='Otro...' >Otro...<\/option><\/select><\/div><\/div><div id=\"field_17_64\" class=\"gfield gfield--type-text gfield--input-type-text optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_64'>\u00bfCu\u00e1l es su orientaci\u00f3n sexual?<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_17_64' type='text' value='' class='small'    placeholder='Por favor especifique...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_17_72\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfCu\u00e1l de estas opciones mejor describe su experiencia con el trauma?<\/legend><div class='gfield_description' id='gfield_description_17_72'>Marque todos los que aplican.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_72'><div class='gchoice gchoice_17_72_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.1' type='checkbox'  value='Maltrato infantil'  id='choice_17_72_1'   aria-describedby=\"gfield_description_17_72\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_17_72_1' id='label_17_72_1' class='gform-field-label gform-field-label--type-inline'>Maltrato infantil<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_72_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.2' type='checkbox'  value='Violencia de pareja'  id='choice_17_72_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_72_2' id='label_17_72_2' class='gform-field-label gform-field-label--type-inline'>Violencia de pareja<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_72_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.3' type='checkbox'  value='Asalto\/violencia sexual'  id='choice_17_72_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_72_3' id='label_17_72_3' class='gform-field-label gform-field-label--type-inline'>Asalto\/violencia sexual<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_72_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.4' type='checkbox'  value='Enfermedad\/herida\/asalto grave'  id='choice_17_72_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_72_4' id='label_17_72_4' class='gform-field-label gform-field-label--type-inline'>Enfermedad\/herida\/asalto grave<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_72_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.5' type='checkbox'  value='Conflicto familiar (aceptaci\u00f3n de identidad, separaci\u00f3n, divorcio, etc.)'  id='choice_17_72_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_72_5' id='label_17_72_5' class='gform-field-label gform-field-label--type-inline'>Conflicto familiar (aceptaci\u00f3n de identidad, separaci\u00f3n, divorcio, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_72_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.6' type='checkbox'  value='Evento traum\u00e1tico (desastre natural, accidente, presenciar violencia, etc.)'  id='choice_17_72_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_72_6' id='label_17_72_6' class='gform-field-label gform-field-label--type-inline'>Evento traum\u00e1tico (desastre natural, accidente, presenciar violencia, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_72_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.7' type='checkbox'  value='Muerte de un ser querido'  id='choice_17_72_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_72_7' id='label_17_72_7' class='gform-field-label gform-field-label--type-inline'>Muerte de un ser querido<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_72_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.8' type='checkbox'  value='Otro y\/o cu\u00e9ntanos m\u00e1s acerca de su trauma'  id='choice_17_72_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_72_8' id='label_17_72_8' class='gform-field-label gform-field-label--type-inline'>Otro y\/o cu\u00e9ntanos m\u00e1s acerca de su trauma<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_17_73\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_73'>Por favor cu\u00e9ntenos m\u00e1s sobre su experiencia con el trauma:<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_17_73' type='text' value='' class='medium'    placeholder='Cu\u00e9ntenos m\u00e1s...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_17_43\" class=\"gfield gfield--type-html gfield--input-type-html section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2>Acerca de su salud mental<\/h2><\/div><fieldset id=\"field_17_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio optional short field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfAlguna vez ha recibido usted tratamiento\/apoyo para una condici\u00f3n de salud mental?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_25'>\n\t\t\t<div class='gchoice gchoice_17_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='S\u00ed'  id='choice_17_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_25_0' id='label_17_25_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_17_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_25_1' id='label_17_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_17_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full optional short field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfEst\u00e1 recibiendo tratamiento\/apoyo actualmente?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_74'>\n\t\t\t<div class='gchoice gchoice_17_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='S\u00ed'  id='choice_17_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_74_0' id='label_17_74_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='No'  id='choice_17_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_74_1' id='label_17_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_17_81\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full optional traditional limit-3 field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfQu\u00e9 ha impedido que usted buscara tratamiento en el pasado?<\/legend><div class='gfield_description' id='gfield_description_17_81'>Marque hasta tres.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_81'><div class='gchoice gchoice_17_81_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.1' type='checkbox'  value='Quer\u00eda manejar mi salud mental sin ayuda'  id='choice_17_81_1'   aria-describedby=\"gfield_description_17_81\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_17_81_1' id='label_17_81_1' class='gform-field-label gform-field-label--type-inline'>Quer\u00eda manejar mi salud mental sin ayuda<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_81_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.2' type='checkbox'  value='No sab\u00eda c\u00f3mo o d\u00f3nde empezar'  id='choice_17_81_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_81_2' id='label_17_81_2' class='gform-field-label gform-field-label--type-inline'>No sab\u00eda c\u00f3mo o d\u00f3nde empezar<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_81_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.3' type='checkbox'  value='Pensaba que costar\u00eda demasiado'  id='choice_17_81_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_81_3' id='label_17_81_3' class='gform-field-label gform-field-label--type-inline'>Pensaba que costar\u00eda demasiado<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_81_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.4' type='checkbox'  value='No ten\u00eda tiempo'  id='choice_17_81_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_81_4' id='label_17_81_4' class='gform-field-label gform-field-label--type-inline'>No ten\u00eda tiempo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_81_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.5' type='checkbox'  value='No pensaba que me ayudara'  id='choice_17_81_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_81_5' id='label_17_81_5' class='gform-field-label gform-field-label--type-inline'>No pensaba que me ayudara<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_81_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.6' type='checkbox'  value='No me sent\u00eda listo\/a para comenzar el tratamiento'  id='choice_17_81_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_81_6' id='label_17_81_6' class='gform-field-label gform-field-label--type-inline'>No me sent\u00eda listo\/a para comenzar el tratamiento<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_81_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.7' type='checkbox'  value='Me preocupaba lo que la otra gente pudiera pensar o decir'  id='choice_17_81_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_81_7' id='label_17_81_7' class='gform-field-label gform-field-label--type-inline'>Me preocupaba lo que la otra gente pudiera pensar o decir<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_81_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.8' type='checkbox'  value='Tem\u00eda que me metieran en el hospital o que me obligaran a tomar medicamentos'  id='choice_17_81_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_81_8' id='label_17_81_8' class='gform-field-label gform-field-label--type-inline'>Tem\u00eda que me metieran en el hospital o que me obligaran a tomar medicamentos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_81_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.9' type='checkbox'  value='Intent\u00e9, pero no encontraba un tratamiento disponible (no hab\u00eda vacantes, no aceptaban mi seguro m\u00e9dico, etc.)'  id='choice_17_81_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_81_9' id='label_17_81_9' class='gform-field-label gform-field-label--type-inline'>Intent\u00e9, pero no encontraba un tratamiento disponible (no hab\u00eda vacantes, no aceptaban mi seguro m\u00e9dico, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_81_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.11' type='checkbox'  value='Mis padres o tutor no me dejaban, o no quer\u00eda pedirles'  id='choice_17_81_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_81_11' id='label_17_81_11' class='gform-field-label gform-field-label--type-inline'>Mis padres o tutor no me dejaban, o no quer\u00eda pedirles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_81_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.12' type='checkbox'  value='Otro...'  id='choice_17_81_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_81_12' id='label_17_81_12' class='gform-field-label gform-field-label--type-inline'>Otro...<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_17_82\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_82'>\u00bfQu\u00e9 m\u00e1s ha impedido que usted buscara tratamiento en el pasado?<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_17_82' type='text' value='' class='medium'    placeholder='Cu\u00e9ntenos m\u00e1s...'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_17_76\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full traditional limit-3 field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Piense en su test de salud mental. \u00bfCuales son las cosas que contribuyen m\u00e1s a sus problemas de salud mental ahora?<\/legend><div class='gfield_description' id='gfield_description_17_76'>Marque hasta tres.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_76'><div class='gchoice gchoice_17_76_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.1' type='checkbox'  value='El abuso o la violencia'  id='choice_17_76_1'   aria-describedby=\"gfield_description_17_76\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_17_76_1' id='label_17_76_1' class='gform-field-label gform-field-label--type-inline'>El abuso o la violencia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_76_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.2' type='checkbox'  value='Problemas de relaci\u00f3n (con amigos, familia, o pareja)'  id='choice_17_76_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_76_2' id='label_17_76_2' class='gform-field-label gform-field-label--type-inline'>Problemas de relaci\u00f3n (con amigos, familia, o pareja)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_76_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.3' type='checkbox'  value='La imagen corporal'  id='choice_17_76_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_76_3' id='label_17_76_3' class='gform-field-label gform-field-label--type-inline'>La imagen corporal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_76_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.4' type='checkbox'  value='Baja autoestima o autoimagen'  id='choice_17_76_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_76_4' id='label_17_76_4' class='gform-field-label gform-field-label--type-inline'>Baja autoestima o autoimagen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_76_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.5' type='checkbox'  value='Problemas de escuela o trabajo'  id='choice_17_76_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_76_5' id='label_17_76_5' class='gform-field-label gform-field-label--type-inline'>Problemas de escuela o trabajo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_76_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.6' type='checkbox'  value='Problemas financieros'  id='choice_17_76_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_76_6' id='label_17_76_6' class='gform-field-label gform-field-label--type-inline'>Problemas financieros<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_76_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.7' type='checkbox'  value='La soledad o el aislamiento'  id='choice_17_76_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_76_7' id='label_17_76_7' class='gform-field-label gform-field-label--type-inline'>La soledad o el aislamiento<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_76_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.8' type='checkbox'  value='El duelo o la p\u00e9rdida de algo o alguien'  id='choice_17_76_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_76_8' id='label_17_76_8' class='gform-field-label gform-field-label--type-inline'>El duelo o la p\u00e9rdida de algo o alguien<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_76_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.9' type='checkbox'  value='Ser el recipiente del odio\/la intimaci\u00f3n\/&quot;bullying&quot; (incluso el racismo, la homofobia, la transfobia, o la discriminaci\u00f3n)'  id='choice_17_76_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_76_9' id='label_17_76_9' class='gform-field-label gform-field-label--type-inline'>Ser el recipiente del odio\/la intimaci\u00f3n\/\"bullying\" (incluso el racismo, la homofobia, la transfobia, o la discriminaci\u00f3n)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_76_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.11' type='checkbox'  value='El estado del mundo (la guerra, el clima, la pol\u00edtica, la inmigraci\u00f3n)'  id='choice_17_76_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_76_11' id='label_17_76_11' class='gform-field-label gform-field-label--type-inline'>El estado del mundo (la guerra, el clima, la pol\u00edtica, la inmigraci\u00f3n)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_76_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.12' type='checkbox'  value='No s\u00e9 (algo simplemente se siente mal)'  id='choice_17_76_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_76_12' id='label_17_76_12' class='gform-field-label gform-field-label--type-inline'>No s\u00e9 (algo simplemente se siente mal)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_76_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.13' type='checkbox'  value='Otro...'  id='choice_17_76_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_76_13' id='label_17_76_13' class='gform-field-label gform-field-label--type-inline'>Otro...<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_17_77\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full optional field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_77'>\u00bfQu\u00e9 m\u00e1s contribuye a sus problemas de salud mental ahora?<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_17_77' type='text' value='' class='medium'    placeholder='Cu\u00e9ntenos m\u00e1s...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_17_78\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_78'>\u00bfQu\u00e9 parte del estado del mundo le afecta m\u00e1s?<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_17_78' type='text' value='' class='large'    placeholder='Cu\u00e9ntenos m\u00e1s...'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_17_44\" class=\"gfield gfield--type-html gfield--input-type-html section-title gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2>Sobre su salud<\/h2><\/div><fieldset id=\"field_17_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio optional short field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfActualmente, tiene usted seguro m\u00e9dico?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_29'>\n\t\t\t<div class='gchoice gchoice_17_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='S\u00ed'  id='choice_17_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_29_0' id='label_17_29_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_17_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_29_1' id='label_17_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No s\u00e9'  id='choice_17_29_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_29_2' id='label_17_29_2' class='gform-field-label gform-field-label--type-inline'>No s\u00e9<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_17_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox optional traditional field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00bfTiene alguna de las siguientes condiciones de salud f\u00edsica?<\/legend><div class='gfield_description' id='gfield_description_17_30'>Marque todas las que aplican.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_30'><div class='gchoice gchoice_17_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='Enfermedad de coraz\u00f3n'  id='choice_17_30_1'   aria-describedby=\"gfield_description_17_30\"\/>\n\t\t\t\t\t\t\t\t<label 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gchoice_17_30_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.4' type='checkbox'  value='C\u00e1ncer'  id='choice_17_30_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_30_4' id='label_17_30_4' class='gform-field-label gform-field-label--type-inline'>C\u00e1ncer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_30_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.5' type='checkbox'  value='Artritis u otro dolor cr\u00f3nico'  id='choice_17_30_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_30_5' id='label_17_30_5' class='gform-field-label gform-field-label--type-inline'>Artritis u otro dolor cr\u00f3nico<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_30_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.6' type='checkbox'  value='El asma, la enfermedad pulmonar obstructiva cr\u00f3nica (EPOC) u otras condiciones del pulm\u00f3n'  id='choice_17_30_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_30_6' id='label_17_30_6' class='gform-field-label gform-field-label--type-inline'>El asma, la enfermedad pulmonar obstructiva cr\u00f3nica (EPOC) u otras condiciones del pulm\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_30_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.7' type='checkbox'  value='Trastorno de movimiento (tic involuntario, discinesia tard\u00eda)'  id='choice_17_30_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_30_7' id='label_17_30_7' class='gform-field-label gform-field-label--type-inline'>Trastorno de movimiento (tic involuntario, discinesia tard\u00eda)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_30_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.8' type='checkbox'  value='Problemas digestivos (la enfermedad de Crohn, la colitis, SII\/IBS, etc.)'  id='choice_17_30_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_30_8' id='label_17_30_8' class='gform-field-label gform-field-label--type-inline'>Problemas digestivos (la enfermedad de Crohn, la colitis, SII\/IBS, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_30_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.9' type='checkbox'  value='Condiciones neurol\u00f3gicas (la epilepsia, etc.) o lesi\u00f3n cerebral traum\u00e1tica (LCT)'  id='choice_17_30_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_30_9' id='label_17_30_9' class='gform-field-label gform-field-label--type-inline'>Condiciones neurol\u00f3gicas (la epilepsia, etc.) o lesi\u00f3n cerebral traum\u00e1tica (LCT)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_30_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.11' type='checkbox'  value='Otro...'  id='choice_17_30_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_30_11' id='label_17_30_11' class='gform-field-label 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Todos los derechos reservados. Reproducido con permiso. PRIME-MD \u00ae es una marca de fabrica de Pfizer Inc.<\/p>\n<p><a href=\"https:\/\/screening.mhanational.org\/about-our-mental-health-tests\/\" target=\"_blank\" rel=\"noopener\">Para m\u00e1s informaci\u00f3n sobre nuestras herramientas de detecci\u00f3n, por favor haz clic aqu\u00ed.<\/a><\/p>\n<p><em><strong>Aviso:<\/strong> Pruebas en l\u00ednea de salud mental son para la evaluaci\u00f3n personal y no son instrumentos diagn\u00f3sticos. Se le recomienda compartir sus resultados con un m\u00e9dico o proveedor de atenci\u00f3n m\u00e9dica. 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