{"id":355,"date":"2022-12-02T23:39:08","date_gmt":"2022-12-03T03:39:08","guid":{"rendered":"https:\/\/misimagenes.online\/web\/?p=355"},"modified":"2025-07-30T06:25:31","modified_gmt":"2025-07-30T10:25:31","slug":"encuesta","status":"publish","type":"post","link":"https:\/\/misimagenes.online\/web\/2022\/12\/02\/encuesta\/","title":{"rendered":"Encuesta para Mamograf\u00eda"},"content":{"rendered":"\n<h2 class=\"has-text-align-center has-system-font-font-family wp-block-heading\" style=\"font-size:3rem;font-style:normal;font-weight:100\">Encuesta para Mamograf\u00eda<\/h2>\n\n\n\n<hr class=\"wp-block-separator has-text-color has-alpha-channel-opacity has-background\" style=\"background-color:#292929;color:#292929\"\/>\n\n\n<div class='fluentform ff-default fluentform_wrapper_4  ff_guten_block ff_guten_block-4 ffs_default_wrap'><form data-form_id=\"4\" id=\"fluentform_4\" class=\"frm-fluent-form fluent_form_4 ff-el-form-top ff_form_instance_4_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_4_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Encuesta Mamografia<\/legend>        <div\n                style=\"display: none!important; position: absolute!important; transform: translateX(1000%)!important;\"\n                class=\"ff-el-group ff-hpsf-container\"\n        >\n            <div class=\"ff-el-input--label asterisk-right\">\n                <label for=\"ff_4_item_sf\" aria-label=\"Updates\">\n                    Updates                <\/label>\n            <\/div>\n            <div class=\"ff-el-input--content\">\n                <input type=\"text\"\n                       name=\"item_4__fluent_sf\"\n                       class=\"ff-el-form-control\"\n                       id=\"ff_4_item_sf\"\n                \/>\n            <\/div>\n        <\/div>\n        <input type='hidden' name='__fluent_form_embded_post_id' value='355' \/><input type=\"hidden\" id=\"_fluentform_4_fluentformnonce\" name=\"_fluentform_4_fluentformnonce\" value=\"b0077b2d95\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/web\/wp-json\/wp\/v2\/posts\/355\" \/><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_subject' id='label_ff_4_subject' aria-label=\"C\u00e9dula de Identidad\">C\u00e9dula de Identidad<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"subject\" class=\"ff-el-form-control\" placeholder=\"V si es venezolana, E si es extranjera, as\u00ed: V6293379\" data-name=\"subject\" tabindex=\"1\" id=\"ff_4_subject\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_names_first_name_' id='label_ff_4_names_first_name_' >Primer Nombre<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_4_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Como aparece en la c\u00e9dula\" tabindex=\"2\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div data-type=\"name-element\" data-name=\"Apelllido\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_Apelllido_last_name_' id='label_ff_4_Apelllido_last_name_' >Primer Apellido<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Apelllido[last_name]\" id=\"ff_4_Apelllido_last_name_\" class=\"ff-el-form-control\" placeholder=\"Apellido de Soltera\" tabindex=\"3\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_DOB' id='label_ff_4_DOB' aria-label=\"Fecha de Nacimiento\">Fecha de Nacimiento<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"DOB\" class=\"ff-el-form-control\" placeholder=\"d\u00eda, mes, a\u00f1o, as\u00ed: 12-02-1968\" data-name=\"DOB\" tabindex=\"4\" id=\"ff_4_DOB\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_email' id='label_ff_4_email' aria-label=\"Correo Electr\u00f3nico\">Correo Electr\u00f3nico<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_4_email\" class=\"ff-el-form-control\" placeholder=\"su_email@ejemplo.com\" data-name=\"email\" tabindex=\"5\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_Celular' id='label_ff_4_Celular' aria-label=\"N\u00famero de Celular\">N\u00famero de Celular<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Celular\" class=\"ff-el-form-control\" placeholder=\"Sin rayas ni espacios. As\u00ed: 04166385959\" maxlength=\"12\" data-name=\"Celular\" tabindex=\"6\" id=\"ff_4_Celular\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_Tratante' id='label_ff_4_Tratante' aria-label=\"Nombre del M\u00e9dico Tratante\">Nombre del M\u00e9dico Tratante<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Tratante\" class=\"ff-el-form-control\" placeholder=\"o coloque Particular si es por su cuenta\" data-name=\"Tratante\" tabindex=\"7\" id=\"ff_4_Tratante\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_Piel' id='label_ff_4_Piel' aria-label=\"Color de Piel\">Color de Piel<\/label><\/div><div class='ff-el-input--content'><select name=\"Piel\" id=\"ff_4_Piel\" class=\"ff-el-form-control\" data-name=\"Piel\" data-calc_value=\"0\" tabindex=\"8\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_4_Piel\"><option value=\"\">Seleccione<\/option><option value=\"Morena\"  >Morena<\/option><option value=\"Negra\"  >Negra<\/option><option value=\"Blanca\"  >Blanca<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_Motivo' id='label_ff_4_Motivo' aria-label=\"\u00bfPor qu\u00e9 motivo va a realizarse el estudio?\">\u00bfPor qu\u00e9 motivo va a realizarse el estudio?<\/label><\/div><div class='ff-el-input--content'><select name=\"Motivo\" id=\"ff_4_Motivo\" class=\"ff-el-form-control\" data-name=\"Motivo\" data-calc_value=\"0\" tabindex=\"9\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_4_Motivo\"><option value=\"\">Seleccione<\/option><option value=\"Control Anual\"  >Control Anual<\/option><option value=\"Indicaci\u00f3n del m\u00e9dico\"  >Indicaci\u00f3n del m\u00e9dico<\/option><option value=\"Solicitud por un seguro\"  >Solicitud por un seguro<\/option><option value=\"Por dolor\"  >Por dolor<\/option><option value=\"Porque se palpa un n\u00f3dulo\"  >Porque se palpa un n\u00f3dulo<\/option><\/select><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_Menarquia' id='label_ff_4_Menarquia' aria-label=\"Edad a la Menarquia\">Edad a la Menarquia<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Menarquia\" value=\"11\" class=\"ff-el-form-control\" placeholder=\"\u00bfA qu\u00e9 edad se desarroll\u00f3?\" maxlength=\"2\" data-name=\"Menarquia\" tabindex=\"10\" id=\"ff_4_Menarquia\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_FUR' id='label_ff_4_FUR' aria-label=\"Fecha de la \u00faltima menstruaci\u00f3n\">Fecha de la \u00faltima menstruaci\u00f3n<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"FUR\" class=\"ff-el-form-control\" placeholder=\"o coloque el a\u00f1o de su menopausia\" data-name=\"FUR\" tabindex=\"11\" id=\"ff_4_FUR\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_Edad1erParto' id='label_ff_4_Edad1erParto' aria-label=\"Edad del primer parto\">Edad del primer parto<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Edad1erParto\" value=\"20\" class=\"ff-el-form-control\" placeholder=\"\u00bfCu\u00e1l era su edad cuando tuvo su primer hijo?\" maxlength=\"2\" data-name=\"Edad1erParto\" tabindex=\"12\" id=\"ff_4_Edad1erParto\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_Edad2erParto' id='label_ff_4_Edad2erParto' aria-label=\"\u00bfCu\u00e1ntos hijos tiene?\">\u00bfCu\u00e1ntos hijos tiene?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Edad2erParto\" value=\"0\" class=\"ff-el-form-control\" maxlength=\"2\" data-name=\"Edad2erParto\" tabindex=\"13\" id=\"ff_4_Edad2erParto\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_MmxPrevia' id='label_ff_4_MmxPrevia' aria-label=\"\u00bfTiene una mamograf\u00eda previa a este estudio?\">\u00bfTiene una mamograf\u00eda previa a este estudio?<\/label><\/div><div class='ff-el-input--content'><select name=\"MmxPrevia\" id=\"ff_4_MmxPrevia\" class=\"ff-el-form-control\" data-name=\"MmxPrevia\" data-calc_value=\"0\" tabindex=\"14\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_4_MmxPrevia\"><option value=\"No\"  selected>No<\/option><option value=\"Si\"  >Si<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_QxPreviaDer' id='label_ff_4_QxPreviaDer' aria-label=\"\u00bfHa sido operada de la mama derecha?\">\u00bfHa sido operada de la mama derecha?<\/label><\/div><div class='ff-el-input--content'><select name=\"QxPreviaDer\" id=\"ff_4_QxPreviaDer\" class=\"ff-el-form-control\" data-name=\"QxPreviaDer\" data-calc_value=\"0\" tabindex=\"15\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_4_QxPreviaDer\"><option value=\"\">Seleccione<\/option><option value=\"No, nunca\"  >No, nunca<\/option><option value=\"SI, por un quiste o n\u00f3dulo benigno\"  >SI, por un quiste o n\u00f3dulo benigno<\/option><option value=\"SI, para colocarme Implante (pr\u00f3tesis)\"  >SI, para colocarme Implante (pr\u00f3tesis)<\/option><option value=\"S\u00ed, por cirug\u00eda pl\u00e1stica, pero no tengo implantes\"  >S\u00ed, por cirug\u00eda pl\u00e1stica, pero no tengo implantes<\/option><option value=\"S\u00ed, por c\u00e1ncer\"  >S\u00ed, por c\u00e1ncer<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_QxPreviaIzq' id='label_ff_4_QxPreviaIzq' aria-label=\"\u00bfHa sido operada de la mama izquierda?\">\u00bfHa sido operada de la mama izquierda?<\/label><\/div><div class='ff-el-input--content'><select name=\"QxPreviaIzq\" id=\"ff_4_QxPreviaIzq\" class=\"ff-el-form-control\" data-name=\"QxPreviaIzq\" data-calc_value=\"0\" tabindex=\"16\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_4_QxPreviaIzq\"><option value=\"\">Seleccione<\/option><option value=\"No, nunca\"  >No, nunca<\/option><option value=\"SI, por un quiste o n\u00f3dulo benigno\"  >SI, por un quiste o n\u00f3dulo benigno<\/option><option value=\"SI, para colocarme Implante (pr\u00f3tesis)\"  >SI, para colocarme Implante (pr\u00f3tesis)<\/option><option value=\"S\u00ed, por cirug\u00eda pl\u00e1stica, pero no tengo implantes\"  >S\u00ed, por cirug\u00eda pl\u00e1stica, pero no tengo implantes<\/option><option value=\"S\u00ed, por c\u00e1ncer\"  >S\u00ed, por c\u00e1ncer<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_QxPrevia_2' id='label_ff_4_QxPrevia_2' aria-label=\"\u00bfLe han realizado biopsia de mama?\">\u00bfLe han realizado biopsia de mama?<\/label><\/div><div class='ff-el-input--content'><select name=\"QxPrevia_2\" id=\"ff_4_QxPrevia_2\" class=\"ff-el-form-control\" data-name=\"QxPrevia_2\" data-calc_value=\"0\" tabindex=\"17\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_4_QxPrevia_2\"><option value=\"\">Seleccione<\/option><option value=\"No, nunca\"  >No, nunca<\/option><option value=\"Si, una sola vez\"  >Si, una sola vez<\/option><option value=\"Si, m\u00e1s de una vez\"  >Si, m\u00e1s de una vez<\/option><\/select><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_HiperplasiaCa' id='label_ff_4_HiperplasiaCa' aria-label=\"\u00bfReport\u00f3 hiperplasia at\u00edpica o c\u00e1ncer?\">\u00bfReport\u00f3 hiperplasia at\u00edpica o c\u00e1ncer?<\/label><\/div><div class='ff-el-input--content'><select name=\"HiperplasiaCa\" id=\"ff_4_HiperplasiaCa\" class=\"ff-el-form-control\" data-name=\"HiperplasiaCa\" data-calc_value=\"0\" tabindex=\"18\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_4_HiperplasiaCa\"><option value=\"\">&#8211; Select &#8211;<\/option><option value=\"El estudio report\u00f3 benigno\"  >El estudio report\u00f3 benigno<\/option><option value=\"Report\u00f3 hiperplasia at\u00edpica\"  >Report\u00f3 hiperplasia at\u00edpica<\/option><option value=\"Report\u00f3 c\u00e1ncer de mama\"  >Report\u00f3 c\u00e1ncer de mama<\/option><option value=\"No recuerdo el resultado\"  >No recuerdo el resultado<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_Familiares' id='label_ff_4_Familiares' aria-label=\"\u00bfC\u00e1ncer en alguna hermana, t\u00eda o madre?\">\u00bfC\u00e1ncer en alguna hermana, t\u00eda o madre?<\/label><\/div><div class='ff-el-input--content'><select name=\"Familiares\" id=\"ff_4_Familiares\" class=\"ff-el-form-control\" data-name=\"Familiares\" data-calc_value=\"0\" tabindex=\"19\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_4_Familiares\"><option value=\"\">Seleccione<\/option><option value=\"No, ninguna\"  >No, ninguna<\/option><option value=\"SI, un sola familiar\"  >SI, un sola familiar<\/option><option value=\"SI, m\u00e1s de un familiar\"  >SI, m\u00e1s de un familiar<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_DMO' id='label_ff_4_DMO' aria-label=\"\u00bfSe ha realizado Densitometr\u00eda \u00d3sea?\">\u00bfSe ha realizado Densitometr\u00eda \u00d3sea?<\/label><\/div><div class='ff-el-input--content'><select name=\"DMO\" id=\"ff_4_DMO\" class=\"ff-el-form-control\" data-name=\"DMO\" data-calc_value=\"0\" tabindex=\"20\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_4_DMO\"><option value=\"\">Seleccione<\/option><option value=\"No\"  >No<\/option><option value=\"SI, es normal\"  >SI, es normal<\/option><option value=\"S\u00ed, tengo Osteopenia\"  >S\u00ed, tengo Osteopenia<\/option><option value=\"S\u00ed, tengo Osteoporosis\"  >S\u00ed, tengo Osteoporosis<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_Humo' id='label_ff_4_Humo' aria-label=\"\u00bfFuma?\">\u00bfFuma?<\/label><\/div><div class='ff-el-input--content'><select name=\"Humo\" id=\"ff_4_Humo\" class=\"ff-el-form-control\" data-name=\"Humo\" data-calc_value=\"0\" tabindex=\"21\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_4_Humo\"><option value=\"\">Seleccione<\/option><option value=\"No\"  >No<\/option><option value=\"Ocasionalmente\"  >Ocasionalmente<\/option><option value=\"M\u00e1s de una caja al d\u00eda\"  >M\u00e1s de una caja al d\u00eda<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_Alcohol' id='label_ff_4_Alcohol' aria-label=\"\u00bfToma bebidas alcoh\u00f3licas?\">\u00bfToma bebidas alcoh\u00f3licas?<\/label><\/div><div class='ff-el-input--content'><select name=\"Alcohol\" id=\"ff_4_Alcohol\" class=\"ff-el-form-control\" data-name=\"Alcohol\" data-calc_value=\"0\" tabindex=\"22\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_4_Alcohol\"><option value=\"\">Seleccione<\/option><option value=\"No\"  >No<\/option><option value=\"Ocasionalmente\"  >Ocasionalmente<\/option><option value=\"M\u00e1s de 14 bebidas\/copas por semana\"  >M\u00e1s de 14 bebidas\/copas por semana<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_ACO' id='label_ff_4_ACO' aria-label=\"\u00bfHa tomado hormonas o anticonceptivos?\">\u00bfHa tomado hormonas o anticonceptivos?<\/label><\/div><div class='ff-el-input--content'><select name=\"ACO\" id=\"ff_4_ACO\" class=\"ff-el-form-control\" data-name=\"ACO\" data-calc_value=\"0\" tabindex=\"23\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_4_ACO\"><option value=\"\">Seleccione<\/option><option value=\"No\"  >No<\/option><option value=\"SI, por menos de 9 a\u00f1os\"  >SI, por menos de 9 a\u00f1os<\/option><option value=\"SI, durante m\u00e1s de 9 a\u00f1os\"  >SI, durante m\u00e1s de 9 a\u00f1os<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_Embutidos' id='label_ff_4_Embutidos' aria-label=\"\u00bfCome jam\u00f3n, mortadela, tocineta, etc?\">\u00bfCome jam\u00f3n, mortadela, tocineta, etc?<\/label><\/div><div class='ff-el-input--content'><select name=\"Embutidos\" id=\"ff_4_Embutidos\" class=\"ff-el-form-control\" data-name=\"Embutidos\" data-calc_value=\"0\" tabindex=\"24\"  aria-invalid=\"false\" aria-required=\"true\" 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