<div dir=3D"ltr">
<br clear=3D"all">
<div>
<div dir=3D"ltr" class=3D"gmail_signature" data-smartmail=3D"gmail_signature">
<div dir=3D"ltr">
<div>
<div>
<i>
<font face=3D"times new roman, serif">
Atte</font>
</i>
</div>
<div dir=3D"ltr">
<i>
<font face=3D"times new roman, serif">
Graciela Jes=C3=BAs Fuentes Vel=C3==A1squez</font>
</i>
<div>
<font face=3D"times new roman, serif">
<i>
Licenciada en Psicolog=C3=ADa</i>
</font>
</div>
<div>
<font face=3D"times new roman, serif">
<i>
Psic=C3=B3loga=C2=A0</i>
</font>
</div>
</div>
</div>
</div>
</div>
</div>
<br>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class=3D"gmail_attr">
---------- Forwarded message ---------<br>
From: <strong class=3D"gmail_sendername" dir=3D"auto">
Formularios de Google</strong>
 <span dir=3D"ltr">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: mi=C3=A9., 13 de mar. de 2019 a la(s) 10:06<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:graciela.fuentesv@gmail.com">
graciela.fuentesv@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Formularios de Google" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por llenar <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target=3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Estas son tus respuestas:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_8614869769437335918ss-form-container">
<div class=3D"m_8614869769437335918ss-form-heading">
<h1 class=3D"m_8614869769437335918ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_8614869769437335918ss-form-desc m_8614869769437335918ss-no-ignore-whitespace" style=3D"font:inherit;width:99%;margin:0 0 1em;white-space:pre-wrap;word-wrap:break-word">
Este es el sistema de registro de atenciones domiciliarias de Oncovida.   Debe ser llenado por el prestador individual, y debe realizarse un registro por cada visita domiciliaria.   Si usted no es prestador de Oncovida por favor no llene este formulario.   A continuaci=C3=B3n indique su correo electr=C3=B3nico.</div>
</div>
<div class=3D"m_8614869769437335918ss-form">
<form method=3D"GET" id=3D"m_8614869769437335918ss-form" target=3D"_blank">
<br>
<div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-text" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918emailAddress">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Direcci=C3==B3n de correo electr=C3=B3nico<label for=3D"m_8614869769437335918emailAddress">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_8614869769437335918ss-q-text m_8614869769437335918ss-printable-text-line" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
<a href=3D"mailto:graciela.fuentesv@gmail.com" target=3D"_blank">
graciela.fuentesv@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_8614869769437335918ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_8614869769437335918ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_8614869769437335918ss-page-description m_8614869769437335918ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
Aqu=C3=AD debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-text" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_579114469">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_8614869769437335918itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8614869769437335918ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Graciela Fuentes </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-text" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_1276273985">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_8614869769437335918itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_8614869769437335918ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
18789468-9</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-select" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_133691676">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_8614869769437335918itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
Si asisten m=C3=A1s de 1 prestador simult=C3=A1neamente, cada uno debe hacer un registro independiente</div>
</label>
<select name=3D"entry.133691676" disabled id=3D"m_8614869769437335918entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled selected>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_8614869769437335918ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_8614869769437335918ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_8614869769437335918ss-page-description m_8614869769437335918ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_8614869769437335918ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_8614869769437335918ss-section-description m_8614869769437335918ss-no-ignore-whitespace" style=3D"margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-text" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_823811303">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_8614869769437335918itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_8614869769437335918ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
7880060-7</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-text" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_1959365839">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente<label for=3D"m_8614869769437335918itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8614869769437335918ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Galvarino Aedo</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-select" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_545002227">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_8614869769437335918itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.545002227" disabled id=3D"m_8614869769437335918entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled selected>
COLMENA</option>
 <option value=3D"CONSALUD" disabled>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled>
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled>
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-text" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_1900161356">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_8614869769437335918itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8614869769437335918ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Chill=C3=A1n</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-text" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_1298871758">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_8614869769437335918itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8614869769437335918ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Chill=C3=A1n</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_8614869769437335918ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_8614869769437335918ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_8614869769437335918ss-page-description m_8614869769437335918ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos de la atenci==C3=B3n domiciliaria</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-radio" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_2073233714">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_8614869769437335918itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_8614869769437335918ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_8614869769437335918ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_8614869769437335918ss-choice-item-control m_8614869769437335918goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Domicilio" id=3D"m_8614869769437335918group_1222378237_1" class=3D"m_8614869769437335918ss-q-radio">
</span>
<span class=3D"m_8614869769437335918ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_8614869769437335918ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_8614869769437335918ss-choice-item-control m_8614869769437335918goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Ambulatorio" id=3D"m_8614869769437335918group_1222378237_2" class=3D"m_8614869769437335918ss-q-radio">
</span>
<span class=3D"m_8614869769437335918ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-date" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_1705849412">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha de la Atenci=C3=B3n<label for=3D"m_8614869769437335918itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8614869769437335918ss-q-date">
<div class=3D"m_8614869769437335918ss-datetime-box m_8614869769437335918goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name=3D"entry.1705849412_month" disabled class=3D"m_8614869769437335918ss-month-dropdown" id=3D"m_8614869769437335918entry.1705849412_month">
<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
 <option value=3D"2">
febrero</option>
 <option value=3D"3" selected>
marzo</option>
 <option value=3D"4">
abril</option>
 <option value=3D"5">
mayo</option>
 <option value=3D"6">
junio</option>
 <option value=3D"7">
julio</option>
 <option value=3D"8">
agosto</option>
 <option value=3D"9">
septiembre</option>
 <option value=3D"10">
octubre</option>
 <option value=3D"11">
noviembre</option>
 <option value=3D"12">
diciembre</option>
</select>
   <select name=3D"entry.1705849412_day" disabled class=3D"m_8614869769437335918ss-day-dropdown" id=3D"m_8614869769437335918entry.1705849412_day">
<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
 <option value=3D"2">
2</option>
 <option value=3D"3">
3</option>
 <option value=3D"4">
4</option>
 <option value=3D"5">
5</option>
 <option value=3D"6">
6</option>
 <option value=3D"7">
7</option>
 <option value=3D"8">
8</option>
 <option value=3D"9">
9</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12" selected>
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value==3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_8614869769437335918entry.1705849412_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
 <option value=3D"1898">
1898</option>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
1901</option>
 <option value=3D"1902">
1902</option>
 <option value=3D"1903">
1903</option>
 <option value=3D"1904">
1904</option>
 <option value=3D"1905">
1905</option>
 <option value=3D"1906">
1906</option>
 <option value=3D"1907">
1907</option>
 <option value=3D"1908">
1908</option>
 <option value=3D"1909">
1909</option>
 <option value=3D"1910">
1910</option>
 <option value=3D"1911">
1911</option>
 <option value=3D"1912">
1912</option>
 <option value=3D"1913">
1913</option>
 <option value=3D"1914">
1914</option>
 <option value=3D"1915">
1915</option>
 <option value=3D"1916">
1916</option>
 <option value=3D"1917">
1917</option>
 <option value=3D"1918">
1918</option>
 <option value=3D"1919">
1919</option>
 <option value=3D"1920">
1920</option>
 <option value=3D"1921">
1921</option>
 <option value=3D"1922">
1922</option>
 <option value=3D"1923">
1923</option>
 <option value==3D"1924">
1924</option>
 <option value=3D"1925">
1925</option>
 <option value==3D"1926">
1926</option>
 <option value=3D"1927">
1927</option>
 <option value==3D"1928">
1928</option>
 <option value=3D"1929">
1929</option>
 <option value==3D"1930">
1930</option>
 <option value=3D"1931">
1931</option>
 <option value==3D"1932">
1932</option>
 <option value=3D"1933">
1933</option>
 <option value==3D"1934">
1934</option>
 <option value=3D"1935">
1935</option>
 <option value==3D"1936">
1936</option>
 <option value=3D"1937">
1937</option>
 <option value==3D"1938">
1938</option>
 <option value=3D"1939">
1939</option>
 <option value==3D"1940">
1940</option>
 <option value=3D"1941">
1941</option>
 <option value==3D"1942">
1942</option>
 <option value=3D"1943">
1943</option>
 <option value==3D"1944">
1944</option>
 <option value=3D"1945">
1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
1948</option>
 <option value=3D"1949">
1949</option>
 <option value==3D"1950">
1950</option>
 <option value=3D"1951">
1951</option>
 <option value==3D"1952">
1952</option>
 <option value=3D"1953">
1953</option>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
 <option value=3D"1959">
1959</option>
 <option value==3D"1960">
1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
1976</option>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
 <option value==3D"1980">
1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
 <option value=3D"2011">
2011</option>
 <option value==3D"2012">
2012</option>
 <option value=3D"2013">
2013</option>
 <option value==3D"2014">
2014</option>
 <option value=3D"2015">
2015</option>
 <option value==3D"2016">
2016</option>
 <option value=3D"2017">
2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_206244955">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Hora de la Atenci=C3=B3n<label for=3D"m_8614869769437335918itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8614869769437335918ss-q-time">
<div class=3D"m_8614869769437335918ss-datetime-box m_8614869769437335918goog-inline-block" dir=3D"ltr" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
<select name=3D"entry.206244955_hour" disabled id=3D"m_8614869769437335918entry.206244955_hour">
<option value=3D"">
h</option>
<option value=3D"00">
00</option>
 <option value=3D"01">
01</option>
 <option value=3D"02">
02</option>
 <option value=3D"03">
03</option>
 <option value=3D"04">
04</option>
 <option value=3D"05">
05</option>
 <option value=3D"06">
06</option>
 <option value=3D"07">
07</option>
 <option value=3D"08">
08</option>
 <option value=3D"09">
09</option>
 <option value=3D"10">
10</option>
 <option value=3D"11" selected>
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value==3D"22">
22</option>
 <option value=3D"23">
23</option>
</select>
.<select name=3D"entry.206244955_minute" disabled id=3D"m_8614869769437335918entry.206244955_minute">
<option value=3D"">
min</option>
<option value=3D"00" selected>
00</option>
 <option value=3D"01">
01</option>
 <option value=3D"02">
02</option>
 <option value=3D"03">
03</option>
 <option value=3D"04">
04</option>
 <option value=3D"05">
05</option>
 <option value=3D"06">
06</option>
 <option value=3D"07">
07</option>
 <option value=3D"08">
08</option>
 <option value=3D"09">
09</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value==3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
 <option value=3D"32">
32</option>
 <option value=3D"33">
33</option>
 <option value=3D"34">
34</option>
 <option value=3D"35">
35</option>
 <option value=3D"36">
36</option>
 <option value=3D"37">
37</option>
 <option value=3D"38">
38</option>
 <option value=3D"39">
39</option>
 <option value=3D"40">
40</option>
 <option value=3D"41">
41</option>
 <option value=3D"42">
42</option>
 <option value=3D"43">
43</option>
 <option value=3D"44">
44</option>
 <option value=3D"45">
45</option>
 <option value=3D"46">
46</option>
 <option value=3D"47">
47</option>
 <option value=3D"48">
48</option>
 <option value=3D"49">
49</option>
 <option value=3D"50">
50</option>
 <option value=3D"51">
51</option>
 <option value=3D"52">
52</option>
 <option value=3D"53">
53</option>
 <option value=3D"54">
54</option>
 <option value=3D"55">
55</option>
 <option value=3D"56">
56</option>
 <option value=3D"57">
57</option>
 <option value=3D"58">
58</option>
 <option value=3D"59">
59</option>
</select>
<div class=3D"m_8614869769437335918ss-datetime-box-spacer m_8614869769437335918goog-inline-block" style=3D"height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-select" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_1747608258">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_8614869769437335918itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.1747608258" disabled id=3D"m_8614869769437335918entry_1747608258">
<option value=3D"">
</option>
<option value=3D"0" disabled selected>
0</option>
 <option value=3D"1" disabled>
1</option>
 <option value=3D"2" disabled>
2</option>
 <option value=3D"3" disabled>
3</option>
 <option value=3D"4" disabled>
4</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_1716090865">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_8614869769437335918entry_1421689035">
<tbody>
<tr>
<td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1421689035_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_8614869769437335918ss-scalerow m_8614869769437335918ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_8614869769437335918aria-todo">
</div>
</td>
<td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled checked value=3D"0" id=3D"m_8614869769437335918group_1421689035_1" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value==3D"1" id=3D"m_8614869769437335918group_1421689035_2" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"2" id=3D"m_8614869769437335918group_1421689035_3" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3" id=3D"m_8614869769437335918group_1421689035_4" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_8614869769437335918group_1421689035_5" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_8614869769437335918group_1421689035_6" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_8614869769437335918group_1421689035_7" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"7" id=3D"m_8614869769437335918group_1421689035_8" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_8614869769437335918group_1421689035_9" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_8614869769437335918group_1421689035_10" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class==3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name==3D"entry.1421689035" disabled value=3D"10" id=3D"m_8614869769437335918group_1421689035_11" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
<td class=3D"m_8614869769437335918ss-scalerow m_8614869769437335918ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_2064050596">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=A1ximo</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_8614869769437335918entry_1244707512">
<tbody>
<tr>
<td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_8614869769437335918ss-scalerow m_8614869769437335918ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_8614869769437335918aria-todo">
</div>
</td>
<td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"0" id=3D"m_8614869769437335918group_1244707512_1" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"1" id=3D"m_8614869769437335918group_1244707512_2" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"2" id=3D"m_8614869769437335918group_1244707512_3" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"3" id=3D"m_8614869769437335918group_1244707512_4" class==3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"4" id=3D"m_8614869769437335918group_1244707512_5" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"5" id=3D"m_8614869769437335918group_1244707512_6" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"6" id=3D"m_8614869769437335918group_1244707512_7" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"7" id==3D"m_8614869769437335918group_1244707512_8" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"8" id=3D"m_8614869769437335918group_1244707512_9" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"9" id=3D"m_8614869769437335918group_1244707512_10" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled checked value=3D"10" id=3D"m_8614869769437335918group_1244707512_11" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
<td class=3D"m_8614869769437335918ss-scalerow m_8614869769437335918ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_2000523015">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=ADnimo</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_8614869769437335918entry_853118630">
<tbody>
<tr>
<td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_853118630_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for==3D"m_8614869769437335918group_853118630_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_853118630_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_853118630_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class==3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_853118630_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_853118630_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_853118630_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_853118630_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_853118630_9" style==3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_853118630_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8614869769437335918ss-scalenumber" for=3D"m_8614869769437335918group_853118630_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_8614869769437335918ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_8614869769437335918ss-scalerow m_8614869769437335918ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_8614869769437335918aria-todo">
</div>
</td>
<td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"0" id=3D"m_8614869769437335918group_853118630_1" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled checked value=3D"1" id=3D"m_8614869769437335918group_853118630_2" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"2" id=3D"m_8614869769437335918group_853118630_3" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"3" id=3D"m_8614869769437335918group_853118630_4" class==3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"4" id=3D"m_8614869769437335918group_853118630_5" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"5" id=3D"m_8614869769437335918group_853118630_6" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"6" id=3D"m_8614869769437335918group_853118630_7" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"7" id=3D"m_8614869769437335918group_853118630_8" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"8" id=3D"m_8614869769437335918group_853118630_9" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"9" id=3D"m_8614869769437335918group_853118630_10" class=3D"m_8614869769437335918ss-q-radio">
</div>
</td>
 <td class=3D"m_8614869769437335918ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_8614869769437335918ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"10" id=3D"m_8614869769437335918group_853118630_11" class==3D"m_8614869769437335918ss-q-radio">
</div>
</td>
<td class=3D"m_8614869769437335918ss-scalerow m_8614869769437335918ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_2140974612">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Anamnesis/Evoluci=C3=B3n<label for=3D"m_8614869769437335918itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8614869769437335918ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Paciente con buen estado an=C3=ADmico.=20Se encuentra preocupado por problema de vivienda de su hijo, diciendo que no puede ayudarlo ya que no tiene espacio en su casa para recibirlo. Este hecho lo hizo mantenerse distanciado por unos d=C3=ADas con su esposa ya que ella quer=C3=ADa que le comprara una casa a su hijo, don Galvarino dec=C3==ADa que su esposa no entiende que es una persona enferma y no puede pedir cr=C3=A9ditos al banco por el certificado de salud que le pedir=C3=ADan.Por otro lado se encuentra ansioso por su pensi=C3=B3n de invalidez, donde los doctores locales le dieron un 85% de invalidez, pero debe esperar la respuesta de los m=C3=A9dicos de la compa=C3=B1=C3=ADa de seguro en dos semanas m=C3=A1s.=20Al finalizar la sesi=C3=B3n me muestra orgulloso las fotos que est=C3=A1n en la muralla de su familia.</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_824006088">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen F=C3=ADsico<label for=3D"m_8614869769437335918itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8614869769437335918ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Paciente en buen estado fisico</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-text" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_1690694733">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_8614869769437335918itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8614869769437335918ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Ansiedad por resoluci=C3=B3n de pensi==C3=B3n de invalidez</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-item-required m_8614869769437335918ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_1255665248">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_8614869769437335918itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8614869769437335918ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8614869769437335918ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Trabajo en contenci=C3=B3n para disminuir la ansiedad</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_1648939075">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8614869769437335918ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-date" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_2063615873">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8614869769437335918ss-q-date">
<div class=3D"m_8614869769437335918ss-datetime-box m_8614869769437335918goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name=3D"entry.2063615873_month" disabled class=3D"m_8614869769437335918ss-month-dropdown" id=3D"m_8614869769437335918entry.2063615873_month">
<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
 <option value=3D"2">
febrero</option>
 <option value=3D"3" selected>
marzo</option>
 <option value=3D"4">
abril</option>
 <option value=3D"5">
mayo</option>
 <option value=3D"6">
junio</option>
 <option value=3D"7">
julio</option>
 <option value=3D"8">
agosto</option>
 <option value=3D"9">
septiembre</option>
 <option value=3D"10">
octubre</option>
 <option value=3D"11">
noviembre</option>
 <option value=3D"12">
diciembre</option>
</select>
   <select name=3D"entry.2063615873_day" disabled class=3D"m_8614869769437335918ss-day-dropdown" id=3D"m_8614869769437335918entry.2063615873_day">
<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
 <option value=3D"2">
2</option>
 <option value=3D"3">
3</option>
 <option value=3D"4">
4</option>
 <option value=3D"5">
5</option>
 <option value=3D"6">
6</option>
 <option value=3D"7">
7</option>
 <option value=3D"8">
8</option>
 <option value=3D"9">
9</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value==3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19" selected>
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
</select>
=20<select name=3D"entry.2063615873_year" disabled id=3D"m_8614869769437335918entry.2063615873_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
 <option value=3D"1898">
1898</option>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
1901</option>
 <option value=3D"1902">
1902</option>
 <option value=3D"1903">
1903</option>
 <option value=3D"1904">
1904</option>
 <option value=3D"1905">
1905</option>
 <option value=3D"1906">
1906</option>
 <option value=3D"1907">
1907</option>
 <option value=3D"1908">
1908</option>
 <option value=3D"1909">
1909</option>
 <option value=3D"1910">
1910</option>
 <option value=3D"1911">
1911</option>
 <option value=3D"1912">
1912</option>
 <option value=3D"1913">
1913</option>
 <option value=3D"1914">
1914</option>
 <option value=3D"1915">
1915</option>
 <option value=3D"1916">
1916</option>
 <option value=3D"1917">
1917</option>
 <option value=3D"1918">
1918</option>
 <option value=3D"1919">
1919</option>
 <option value=3D"1920">
1920</option>
 <option value=3D"1921">
1921</option>
 <option value=3D"1922">
1922</option>
 <option value=3D"1923">
1923</option>
 <option value==3D"1924">
1924</option>
 <option value=3D"1925">
1925</option>
 <option value==3D"1926">
1926</option>
 <option value=3D"1927">
1927</option>
 <option value==3D"1928">
1928</option>
 <option value=3D"1929">
1929</option>
 <option value==3D"1930">
1930</option>
 <option value=3D"1931">
1931</option>
 <option value==3D"1932">
1932</option>
 <option value=3D"1933">
1933</option>
 <option value==3D"1934">
1934</option>
 <option value=3D"1935">
1935</option>
 <option value==3D"1936">
1936</option>
 <option value=3D"1937">
1937</option>
 <option value==3D"1938">
1938</option>
 <option value=3D"1939">
1939</option>
 <option value==3D"1940">
1940</option>
 <option value=3D"1941">
1941</option>
 <option value==3D"1942">
1942</option>
 <option value=3D"1943">
1943</option>
 <option value==3D"1944">
1944</option>
 <option value=3D"1945">
1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
1948</option>
 <option value=3D"1949">
1949</option>
 <option value==3D"1950">
1950</option>
 <option value=3D"1951">
1951</option>
 <option value==3D"1952">
1952</option>
 <option value=3D"1953">
1953</option>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
 <option value=3D"1959">
1959</option>
 <option value==3D"1960">
1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
1976</option>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
 <option value==3D"1980">
1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
 <option value=3D"2011">
2011</option>
 <option value==3D"2012">
2012</option>
 <option value=3D"2013">
2013</option>
 <option value==3D"2014">
2014</option>
 <option value=3D"2015">
2015</option>
 <option value==3D"2016">
2016</option>
 <option value=3D"2017">
2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-text" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_74766472">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8614869769437335918ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918ss-form-question m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8614869769437335918ss-q-item-label" for=3D"m_8614869769437335918entry_1219705969">
<div class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_8614869769437335918ss-q-help m_8614869769437335918ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
</label>
<ul class=3D"m_8614869769437335918ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_8614869769437335918ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_8614869769437335918ss-choice-item-control m_8614869769437335918goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"ENFERMERA" id=3D"m_8614869769437335918group_503039759_1" class=3D"m_8614869769437335918ss-q-checkbox">
</span>
<span class=3D"m_8614869769437335918ss-choice-label">
ENFERMERA</span>
</label>
</li>
 <li class=3D"m_8614869769437335918ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_8614869769437335918ss-choice-item-control m_8614869769437335918goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_8614869769437335918group_503039759_2" class=3D"m_8614869769437335918ss-q-checkbox">
</span>
<span class=3D"m_8614869769437335918ss-choice-label">
TENS</span>
</label>
</li>
 <li class=3D"m_8614869769437335918ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_8614869769437335918ss-choice-item-control m_8614869769437335918goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id==3D"m_8614869769437335918group_503039759_3" class=3D"m_8614869769437335918ss-q-checkbox">
</span>
<span class=3D"m_8614869769437335918ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
 <li class=3D"m_8614869769437335918ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_8614869769437335918ss-choice-item-control m_8614869769437335918goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"KINESIOLOGO" id=3D"m_8614869769437335918group_503039759_4" class=3D"m_8614869769437335918ss-q-checkbox">
</span>
<span class=3D"m_8614869769437335918ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
 <li class=3D"m_8614869769437335918ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_8614869769437335918ss-choice-item-control m_8614869769437335918goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"PSICOLOGO" id=3D"m_8614869769437335918group_503039759_5" class=3D"m_8614869769437335918ss-q-checkbox">
</span>
<span class=3D"m_8614869769437335918ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_8614869769437335918errorbox-good">
<div dir=3D"auto" class=3D"m_8614869769437335918ss-item m_8614869769437335918ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_8614869769437335918ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_8614869769437335918ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_8614869769437335918ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
</form>
</div>
</div>
</td>
</tr>
<tr height=3D"24px">
</tr>
</tbody>
</table>
</div>
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"max-width:672px;min-width:154px" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242;font-size:13px" target=3D"_blank">
Crear tu propio Formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
--0000000000005c699f0583f97eda--