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Junto con saludar envio registro de visita&nbsp;</div>
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saluda atte</div>
<div style=3D"color: rgb(0, 0, 0); font-family: Calibri,Helvetica,sans-serif; font-size: 12pt;">
Pamela Gonz=E1lez Jorquera&nbsp;</div>
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<b>
De:</b>
 Formularios de Google &lt;forms-receipts-noreply@google.com&gt;<br>
<b>
Enviado:</b>
 lunes, 15 de abril de 2019 3:13<br>
<b>
Para:</b>
 pamelocha-67@hotmail.com<br>
<b>
Asunto:</b>
 Registro de Atenci=F3n Domiciliaria Oncovida</font>
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&nbsp;</div>
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<table width=3D"100%" role=3D"presentation" style=3D"background-color:rgb(38,4,154)" border=3D"0" cellspacing=3D"0" cellpadding=3D"0">
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<img width=3D"143" height=3D"26" style=3D"display:inline-block; margin:0; vertical-align:middle" alt=3D"Formularios de Google" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
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<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 width=3D"100%" align=3D"center" role=3D"presentation" style=3D"background-color:#fff" cellspacing=3D"0" cellpadding=3D"0">
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<div style=3D"font-size:13px; line-height:18px; color:#424242; font-weight:700">
Gracias por rellenar<a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link">
Registro de Atenci=F3n Domiciliaria Oncovida</a>
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Esto es lo que nos has enviado:</div>
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<td>
<div class=3D"ss-form-container" style=3D"">
<div class=3D"ss-form-heading" style=3D"">
<h1 class=3D"ss-form-title" style=3D"margin:.67em 0" dir=3D"ltr">
Registro de Atenci=F3n Domiciliaria Oncovida</h1>
<div class=3D"ss-form-desc ss-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=F3n indique su correo electr=F3nico.</div>
</div>
<div class=3D"ss-form" style=3D"">
<form id=3D"ss-form" style=3D"" action=3D"" method=3D"GET">
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" style=3D"" for=3D"emailAddress">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Direcci=F3n de correo electr=F3nico <label style=3D"" aria-label=3D"(Campo obligatorio)" for=3D"emailAddress">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"ss-q-text ss-printable-text-line" style=3D"background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%" dir=3D"auto">
pamelocha-67@hotmail.com</div>
</div>
</div>
</div>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item  ss-embeddable-object-container" style=3D"margin:12px 0; max-width:100%" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img title=3D"" class=3D"ss-image" style=3D"width:78px; outline:none" alt=3D"Imagen sin leyenda" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ">
</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item  ss-page-break" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-page-title" style=3D"padding:0.4em; background-color:#eee">
Identificaci=F3n del Prestador</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" style=3D"white-space:pre-wrap; word-wrap:break-word" dir=3D"auto">
Aqu=ED debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" style=3D"" for=3D"entry_579114469">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Primer Nombre y Apellido Paterno <label style=3D"" aria-label=3D"(Campo obligatorio)" for=3D"itemView.getDomIdToLabel()">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" style=3D"display:block; margin:.1em 0 .25em 0; color:#666" dir=3D"auto">
</div>
</label>
<div class=3D"ss-q-text" style=3D"background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%" dir=3D"auto">
Pamela Gonz=E1lez </div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" style=3D"" for=3D"entry_1276273985">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
RUT <label style=3D"" aria-label=3D"(Campo obligatorio)" for=3D"itemView.getDomIdToLabel()">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" style=3D"display:block; margin:.1em 0 .25em 0; color:#666" dir=3D"auto">
RUT con Gui=F3n y D=EDgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"ss-q-text" style=3D"background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%" dir=3D"auto">
17333372-2</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item ss-item-required ss-select" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" style=3D"" for=3D"entry_133691676">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Tipo <label style=3D"" aria-label=3D"(Campo obligatorio)" for=3D"itemView.getDomIdToLabel()">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" style=3D"display:block; margin:.1em 0 .25em 0; color:#666" dir=3D"auto">
Si asisten m=E1s de 1 prestador simult=E1neamente, cada uno debe hacer un registro independiente</div>
</label>
<select name=3D"entry.133691676" disabled=3D"" id=3D"entry_133691676" style=3D"" aria-label=3D"Tipo Si asisten m=E1s de 1 prestador simult=E1neamente, cada uno debe hacer un registro independiente ">
<option style=3D"" value=3D"">
</option>
 <option disabled=3D"" style=3D"" value=3D"MEDICO">
MEDICO</option>
 <option disabled=3D"" style=3D"" value=3D"ENFERMERA/O" selected=3D"">
ENFERMERA/O</option>
 <option disabled=3D"" style=3D"" value=3D"TENS">
TENS</option>
 <option disabled=3D"" style=3D"" value=3D"KINESIOLOGA/O">
KINESIOLOGA/O</option>
 <option disabled=3D"" style=3D"" value=3D"PSICOLOGO">
PSICOLOGO</option>
<option disabled=3D"" style=3D"" value=3D"NUTRICIONISTA">
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item  ss-embeddable-object-container" style=3D"margin:12px 0; max-width:100%" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img title=3D"" class=3D"ss-image" style=3D"width:78px; outline:none" alt=3D"Imagen sin leyenda" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA">
</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item  ss-page-break" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-page-title" style=3D"padding:0.4em; background-color:#eee">
Identificaci=F3n del Paciente</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" style=3D"white-space:pre-wrap; word-wrap:break-word" dir=3D"auto">
En esta secci=F3n debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item  ss-section-header" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-section-title" style=3D"background-color:#eee; padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"ss-section-description ss-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"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" style=3D"" for=3D"entry_823811303">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Ingrese el Rut del Paciente <label style=3D"" aria-label=3D"(Campo obligatorio)" for=3D"itemView.getDomIdToLabel()">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" style=3D"display:block; margin:.1em 0 .25em 0; color:#666" dir=3D"auto">
RUT con Gui=F3n y D=EDgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"ss-q-text" style=3D"background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%" dir=3D"auto">
6149748-k</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" style=3D"" for=3D"entry_1959365839">
<div class=3D"ss-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 style=3D"" aria-label=3D"(Campo obligatorio)" for=3D"itemView.getDomIdToLabel()">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" style=3D"display:block; margin:.1em 0 .25em 0; color:#666" dir=3D"auto">
</div>
</label>
<div class=3D"ss-q-text" style=3D"background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%" dir=3D"auto">
XIMENA PALOMINO PARDO</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item ss-item-required ss-select" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" style=3D"" for=3D"entry_545002227">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Previsi=F3n <label style=3D"" aria-label=3D"(Campo obligatorio)" for=3D"itemView.getDomIdToLabel()">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" style=3D"display:block; margin:.1em 0 .25em 0; color:#666" dir=3D"auto">
</div>
</label>
<select name=3D"entry.545002227" disabled=3D"" id=3D"entry_545002227" style=3D"" aria-label=3D"Previsi=F3n  ">
<option style=3D"" value=3D"">
</option>
 <option disabled=3D"" style=3D"" value=3D"BANMEDICA" selected=3D"">
BANMEDICA</option>
<option disabled=3D"" style=3D"" value=3D"CAPREDENA">
CAPREDENA</option>
 <option disabled=3D"" style=3D"" value=3D"COLMENA">
COLMENA</option>
 <option disabled=3D"" style=3D"" value=3D"CONSALUD">
CONSALUD</option>
 <option disabled=3D"" style=3D"" value=3D"CRUZ BLANCA">
CRUZ BLANCA</option>
 <option disabled=3D"" style=3D"" value=3D"DIPRECA">
DIPRECA</option>
<option disabled=3D"" style=3D"" value=3D"FONASA">
FONASA</option>
 <option disabled=3D"" style=3D"" value=3D"FUNDACION">
FUNDACION</option>
 <option disabled=3D"" style=3D"" value=3D"ISAPRES DEL COBRE">
ISAPRES DEL COBRE</option>
 <option disabled=3D"" style=3D"" value=3D"NUEVA MASVIDA">
NUEVA MASVIDA</option>
<option disabled=3D"" style=3D"" value=3D"VIDATRES">
VIDATRES</option>
 <option disabled=3D"" style=3D"" value=3D"PARTICULAR">
PARTICULAR</option>
</select>
 </div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" style=3D"" for=3D"entry_1900161356">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Ciudad <label style=3D"" aria-label=3D"(Campo obligatorio)" for=3D"itemView.getDomIdToLabel()">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" style=3D"display:block; margin:.1em 0 .25em 0; color:#666" dir=3D"auto">
</div>
</label>
<div class=3D"ss-q-text" style=3D"background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%" dir=3D"auto">
san vicente de tagua tagua </div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" style=3D"" for=3D"entry_1298871758">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Comuna <label style=3D"" aria-label=3D"(Campo obligatorio)" for=3D"itemView.getDomIdToLabel()">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" style=3D"display:block; margin:.1em 0 .25em 0; color:#666" dir=3D"auto">
</div>
</label>
<div class=3D"ss-q-text" style=3D"background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%" dir=3D"auto">
san vicente de tagua tagua </div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item  ss-embeddable-object-container" style=3D"margin:12px 0; max-width:100%" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img title=3D"" class=3D"ss-image" style=3D"width:78px; outline:none" alt=3D"Imagen sin leyenda" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ">
</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item  ss-page-break" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-page-title" style=3D"padding:0.4em; background-color:#eee">
Registro de la Atenci=F3n Domiciliaria</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" style=3D"white-space:pre-wrap; word-wrap:break-word" dir=3D"auto">
En esta secci=F3n debe ingresar los datos de la atenci=F3n domiciliaria</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item ss-item-required ss-radio" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" style=3D"" for=3D"entry_2073233714">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Tipo de Atenci=F3n <label style=3D"" aria-label=3D"(Campo obligatorio)" for=3D"itemView.getDomIdToLabel()">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" style=3D"display:block; margin:.1em 0 .25em 0; color:#666" dir=3D"auto">
</div>
</label>
<ul class=3D"ss-choices" role=3D"radiogroup" style=3D"list-style:none; padding:0; margin:.5em 0 0" aria-label=3D"Tipo de Atenci=F3n  ">
<li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input name=3D"entry.1222378237" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1222378237_1" role=3D"radio" style=3D"" aria-label=3D"Domicilio" type=3D"radio" checked=3D"" value=3D"Domicilio">
</span>
<span class=3D"ss-choice-label" style=3D"">
Domicilio</span>
 </label>
</li>
<li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input name=3D"entry.1222378237" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1222378237_2" role=3D"radio" style=3D"" aria-label=3D"Ambulatorio" type=3D"radio" value=3D"Ambulatorio">
</span>
<span class=3D"ss-choice-label" style=3D"">
Ambulatorio</span>
 </label>
</li>
</ul>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item ss-item-required ss-date" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" style=3D"" for=3D"entry_1705849412">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Fecha de la Atenci=F3n <label style=3D"" aria-label=3D"(Campo obligatorio)" for=3D"itemView.getDomIdToLabel()">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" style=3D"display:block; margin:.1em 0 .25em 0; color:#666" dir=3D"auto">
</div>
</label>
<div class=3D"ss-q-date" role=3D"group" style=3D"" aria-label=3D"Fecha de la Atenci=F3n  ">
<div class=3D"ss-datetime-box goog-inline-block" role=3D"group" 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_day" disabled=3D"" class=3D"ss-day-dropdown" id=3D"entry.1705849412_day" style=3D"" aria-label=3D"D=EDa del mes">
<option style=3D"" value=3D"">
D=EDa</option>
 <option style=3D"" value=3D"1">
1</option>
 <option style=3D"" value=3D"2">
2</option>
<option style=3D"" value=3D"3">
3</option>
 <option style=3D"" value=3D"4">
4</option>
 <option style=3D"" value=3D"5">
5</option>
 <option style=3D"" value=3D"6">
6</option>
 <option style=3D"" value=3D"7">
7</option>
<option style=3D"" value=3D"8">
8</option>
 <option style=3D"" value=3D"9">
9</option>
 <option style=3D"" value=3D"10">
10</option>
 <option style=3D"" value=3D"11" selected=3D"">
11</option>
 <option style=3D"" value=3D"12">
12</option>
 <option style=3D"" value=3D"13">
13</option>
 <option style=3D"" value=3D"14">
14</option>
 <option style=3D"" value=3D"15">
15</option>
 <option style=3D"" value=3D"16">
16</option>
<option style=3D"" value=3D"17">
17</option>
 <option style=3D"" value=3D"18">
18</option>
 <option style=3D"" value=3D"19">
19</option>
 <option style=3D"" value=3D"20">
20</option>
 <option style=3D"" value=3D"21">
21</option>
 <option style=3D"" value=3D"22">
22</option>
 <option style=3D"" value=3D"23">
23</option>
<option style=3D"" value=3D"24">
24</option>
 <option style=3D"" value=3D"25">
25</option>
 <option style=3D"" value=3D"26">
26</option>
 <option style=3D"" value=3D"27">
27</option>
 <option style=3D"" value=3D"28">
28</option>
 <option style=3D"" value=3D"29">
29</option>
 <option style=3D"" value=3D"30">
30</option>
<option style=3D"" value=3D"31">
31</option>
</select>
 <select name=3D"entry.1705849412_month" disabled=3D"" class=3D"ss-month-dropdown" id=3D"entry.1705849412_month" style=3D"" aria-label=3D"Mes">
<option style=3D"" value=3D"">
Mes</option>
 <option style=3D"" value=3D"1">
enero</option>
 <option style=3D"" value=3D"2">
febrero</option>
 <option style=3D"" value=3D"3">
marzo</option>
 <option style=3D"" value=3D"4" selected=3D"">
abril</option>
 <option style=3D"" value=3D"5">
mayo</option>
 <option style==3D"" value=3D"6">
junio</option>
 <option style=3D"" value=3D"7">
julio</option>
 <option style==3D"" value=3D"8">
agosto</option>
 <option style=3D"" value=3D"9">
septiembre</option>
 <option style=3D"" value=3D"10">
octubre</option>
 <option style=3D"" value=3D"11">
noviembre</option>
 <option style=3D"" value=3D"12">
diciembre</option>
</select>
 <select name=3D"entry.1705849412_year" disabled=3D"" id=3D"entry.1705849412_year" style=3D"" aria-label=3D"A=F1o">
<option style=3D"" value=3D"">
A=F1o</option>
 <option style=3D"" value=3D"1896">
1896</option>
 <option style=3D"" value=3D"1897">
1897</option>
 <option style=3D"" value=3D"1898">
1898</option>
 <option style=3D"" value=3D"1899">
1899</option>
 <option style=3D"" value=3D"1900">
1900</option>
 <option style=3D"" value=3D"1901">
1901</option>
 <option style=3D"" value=3D"1902">
1902</option>
 <option style=3D"" value=3D"1903">
1903</option>
 <option style=3D"" value=3D"1904">
1904</option>
 <option style=3D"" value=3D"1905">
1905</option>
 <option style=3D"" value=3D"1906">
1906</option>
 <option style=3D"" value=3D"1907">
1907</option>
 <option style=3D"" value=3D"1908">
1908</option>
 <option style=3D"" value=3D"1909">
1909</option>
 <option style=3D"" value=3D"1910">
1910</option>
 <option style=3D"" value=3D"1911">
1911</option>
 <option style=3D"" value=3D"1912">
1912</option>
 <option style=3D"" value=3D"1913">
1913</option>
 <option style=3D"" value=3D"1914">
1914</option>
 <option style=3D"" value=3D"1915">
1915</option>
 <option style=3D"" value=3D"1916">
1916</option>
 <option style=3D"" value=3D"1917">
1917</option>
 <option style=3D"" value=3D"1918">
1918</option>
 <option style=3D"" value=3D"1919">
1919</option>
 <option style=3D"" value=3D"1920">
1920</option>
 <option style=3D"" value=3D"1921">
1921</option>
 <option style=3D"" value=3D"1922">
1922</option>
 <option style=3D"" value=3D"1923">
1923</option>
 <option style=3D"" value=3D"1924">
1924</option>
 <option style=3D"" value=3D"1925">
1925</option>
 <option style=3D"" value=3D"1926">
1926</option>
 <option style=3D"" value=3D"1927">
1927</option>
 <option style=3D"" value=3D"1928">
1928</option>
 <option style=3D"" value=3D"1929">
1929</option>
 <option style=3D"" value=3D"1930">
1930</option>
 <option style=3D"" value=3D"1931">
1931</option>
 <option style=3D"" value=3D"1932">
1932</option>
 <option style=3D"" value=3D"1933">
1933</option>
 <option style=3D"" value=3D"1934">
1934</option>
 <option style=3D"" value=3D"1935">
1935</option>
 <option style=3D"" value=3D"1936">
1936</option>
 <option style=3D"" value=3D"1937">
1937</option>
 <option style=3D"" value=3D"1938">
1938</option>
 <option style=3D"" value=3D"1939">
1939</option>
 <option style=3D"" value=3D"1940">
1940</option>
 <option style=3D"" value=3D"1941">
1941</option>
 <option style=3D"" value=3D"1942">
1942</option>
 <option style=3D"" value=3D"1943">
1943</option>
 <option style=3D"" value=3D"1944">
1944</option>
 <option style=3D"" value=3D"1945">
1945</option>
 <option style=3D"" value=3D"1946">
1946</option>
 <option style=3D"" value=3D"1947">
1947</option>
 <option style=3D"" value=3D"1948">
1948</option>
 <option style=3D"" value=3D"1949">
1949</option>
 <option style=3D"" value=3D"1950">
1950</option>
 <option style=3D"" value=3D"1951">
1951</option>
 <option style=3D"" value=3D"1952">
1952</option>
 <option style=3D"" value=3D"1953">
1953</option>
 <option style=3D"" value=3D"1954">
1954</option>
 <option style=3D"" value=3D"1955">
1955</option>
 <option style=3D"" value=3D"1956">
1956</option>
 <option style=3D"" value=3D"1957">
1957</option>
 <option style=3D"" value=3D"1958">
1958</option>
 <option style=3D"" value=3D"1959">
1959</option>
 <option style=3D"" value=3D"1960">
1960</option>
 <option style=3D"" value=3D"1961">
1961</option>
 <option style=3D"" value=3D"1962">
1962</option>
 <option style=3D"" value=3D"1963">
1963</option>
 <option style=3D"" value=3D"1964">
1964</option>
 <option style=3D"" value=3D"1965">
1965</option>
 <option style=3D"" value=3D"1966">
1966</option>
 <option style=3D"" value=3D"1967">
1967</option>
 <option style=3D"" value=3D"1968">
1968</option>
 <option style=3D"" value=3D"1969">
1969</option>
 <option style=3D"" value=3D"1970">
1970</option>
 <option style=3D"" value=3D"1971">
1971</option>
 <option style=3D"" value=3D"1972">
1972</option>
 <option style=3D"" value=3D"1973">
1973</option>
 <option style=3D"" value=3D"1974">
1974</option>
 <option style=3D"" value=3D"1975">
1975</option>
 <option style=3D"" value=3D"1976">
1976</option>
 <option style=3D"" value=3D"1977">
1977</option>
 <option style=3D"" value=3D"1978">
1978</option>
 <option style=3D"" value=3D"1979">
1979</option>
 <option style=3D"" value=3D"1980">
1980</option>
 <option style=3D"" value=3D"1981">
1981</option>
 <option style=3D"" value=3D"1982">
1982</option>
 <option style=3D"" value=3D"1983">
1983</option>
 <option style=3D"" value=3D"1984">
1984</option>
 <option style=3D"" value=3D"1985">
1985</option>
 <option style=3D"" value=3D"1986">
1986</option>
 <option style=3D"" value=3D"1987">
1987</option>
 <option style=3D"" value=3D"1988">
1988</option>
 <option style=3D"" value=3D"1989">
1989</option>
 <option style=3D"" value=3D"1990">
1990</option>
 <option style=3D"" value=3D"1991">
1991</option>
 <option style=3D"" value=3D"1992">
1992</option>
 <option style=3D"" value=3D"1993">
1993</option>
 <option style=3D"" value=3D"1994">
1994</option>
 <option style=3D"" value=3D"1995">
1995</option>
 <option style=3D"" value=3D"1996">
1996</option>
 <option style=3D"" value=3D"1997">
1997</option>
 <option style=3D"" value=3D"1998">
1998</option>
 <option style=3D"" value=3D"1999">
1999</option>
 <option style=3D"" value=3D"2000">
2000</option>
 <option style=3D"" value=3D"2001">
2001</option>
 <option style=3D"" value=3D"2002">
2002</option>
 <option style=3D"" value=3D"2003">
2003</option>
 <option style=3D"" value=3D"2004">
2004</option>
 <option style=3D"" value=3D"2005">
2005</option>
 <option style=3D"" value=3D"2006">
2006</option>
 <option style=3D"" value=3D"2007">
2007</option>
 <option style=3D"" value=3D"2008">
2008</option>
 <option style=3D"" value=3D"2009">
2009</option>
 <option style=3D"" value=3D"2010">
2010</option>
 <option style=3D"" value=3D"2011">
2011</option>
 <option style=3D"" value=3D"2012">
2012</option>
 <option style=3D"" value=3D"2013">
2013</option>
 <option style=3D"" value=3D"2014">
2014</option>
 <option style=3D"" value=3D"2015">
2015</option>
 <option style=3D"" value=3D"2016">
2016</option>
 <option style=3D"" value=3D"2017">
2017</option>
 <option style=3D"" value=3D"2018">
2018</option>
 <option style=3D"" value=3D"2019" selected=3D"">
2019</option>
 <option style=3D"" value=3D"2020">
2020</option>
 <option style=3D"" value=3D"2021">
2021</option>
 <option style=3D"" value=3D"2022">
2022</option>
 <option style=3D"" value=3D"2023">
2023</option>
 <option style=3D"" value=3D"2024">
2024</option>
 <option style=3D"" value=3D"2025">
2025</option>
 <option style=3D"" value=3D"2026">
2026</option>
 <option style=3D"" value=3D"2027">
2027</option>
 <option style=3D"" value=3D"2028">
2028</option>
 <option style=3D"" value=3D"2029">
2029</option>
 <option style=3D"" value=3D"2030">
2030</option>
 <option style=3D"" value=3D"2031">
2031</option>
 <option style=3D"" value=3D"2032">
2032</option>
 <option style=3D"" value=3D"2033">
2033</option>
 <option style=3D"" value=3D"2034">
2034</option>
 <option style=3D"" value=3D"2035">
2035</option>
 <option style=3D"" value=3D"2036">
2036</option>
 <option style=3D"" value=3D"2037">
2037</option>
 <option style=3D"" value=3D"2038">
2038</option>
 <option style=3D"" value=3D"2039">
2039</option>
 <option style=3D"" value=3D"2040">
2040</option>
 <option style=3D"" value=3D"2041">
2041</option>
 <option style=3D"" value=3D"2042">
2042</option>
 <option style=3D"" value=3D"2043">
2043</option>
 <option style=3D"" value=3D"2044">
2044</option>
 <option style=3D"" value=3D"2045">
2045</option>
 <option style=3D"" value=3D"2046">
2046</option>
 <option style=3D"" value=3D"2047">
2047</option>
 <option style=3D"" value=3D"2048">
2048</option>
 <option style=3D"" value=3D"2049">
2049</option>
 <option style=3D"" value=3D"2050">
2050</option>
 <option style=3D"" value=3D"2051">
2051</option>
 <option style=3D"" value=3D"2052">
2052</option>
 <option style=3D"" value=3D"2053">
2053</option>
 <option style=3D"" value=3D"2054">
2054</option>
 <option style=3D"" value=3D"2055">
2055</option>
 <option style=3D"" value=3D"2056">
2056</option>
 <option style=3D"" value=3D"2057">
2057</option>
 <option style=3D"" value=3D"2058">
2058</option>
 <option style=3D"" value=3D"2059">
2059</option>
 <option style=3D"" value=3D"2060">
2060</option>
 <option style=3D"" value=3D"2061">
2061</option>
 <option style=3D"" value=3D"2062">
2062</option>
 <option style=3D"" value=3D"2063">
2063</option>
 <option style=3D"" value=3D"2064">
2064</option>
 <option style=3D"" value=3D"2065">
2065</option>
 <option style=3D"" value=3D"2066">
2066</option>
 <option style=3D"" value=3D"2067">
2067</option>
 <option style=3D"" value=3D"2068">
2068</option>
 <option style=3D"" value=3D"2069">
2069</option>
</select>
 </div>
</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item ss-item-required ss-time" style=3D"margin:12px 0; font:inherit" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" style=3D"" for=3D"entry_206244955">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Hora de la Atenci=F3n <label style=3D"" aria-label=3D"(Campo obligatorio)" for=3D"itemView.getDomIdToLabel()">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" style=3D"display:block; margin:.1em 0 .25em 0; color:#666" dir=3D"auto">
</div>
</label>
<div class=3D"ss-q-time" style=3D"">
<div class=3D"ss-datetime-box goog-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" dir=3D"ltr">
<select name=3D"entry.206244955_hour" disabled=3D"" id=3D"entry.206244955_hour" style=3D"" aria-label=3D"Hora">
<option style=3D"" value=3D"">
h</option>
 <option style=3D"" value=3D"00">
00</option>
 <option style=3D"" value=3D"01">
01</option>
 <option style=3D"" value=3D"02">
02</option>
 <option style=3D"" value=3D"03">
03</option>
<option style=3D"" value=3D"04">
04</option>
 <option style=3D"" value=3D"05">
05</option>
 <option style=3D"" value=3D"06">
06</option>
 <option style=3D"" value=3D"07">
07</option>
 <option style=3D"" value=3D"08">
08</option>
 <option style=3D"" value=3D"09">
09</option>
 <option style=3D"" value=3D"10">
10</option>
<option style=3D"" value=3D"11">
11</option>
 <option style=3D"" value=3D"12">
12</option>
 <option style=3D"" value=3D"13">
13</option>
 <option style=3D"" value=3D"14">
14</option>
 <option style=3D"" value=3D"15">
15</option>
 <option style=3D"" value=3D"16">
16</option>
 <option style=3D"" value=3D"17" selected=3D"">
17</option>
 <option style=3D"" value=3D"18">
18</option>
 <option style=3D"" value=3D"19">
19</option>
 <option style=3D"" value=3D"20">
20</option>
 <option style=3D"" value=3D"21">
21</option>
<option style=3D"" value=3D"22">
22</option>
 <option style=3D"" value=3D"23">
23</option>
</select>
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01</option>
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02</option>
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03</option>
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04</option>
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06</option>
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07</option>
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08</option>
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09</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
<option style=3D"" value=3D"20">
20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
<option style=3D"" value=3D"27">
27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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32</option>
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33</option>
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34</option>
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35</option>
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36</option>
 <option style=3D"" value=3D"37">
37</option>
<option style=3D"" value=3D"38">
38</option>
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39</option>
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40</option>
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41</option>
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42</option>
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43</option>
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44</option>
<option style=3D"" value=3D"45">
45</option>
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46</option>
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47</option>
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48</option>
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49</option>
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50</option>
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51</option>
<option style=3D"" value=3D"52">
52</option>
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53</option>
 <option style=3D"" value=3D"54">
54</option>
 <option style=3D"" value=3D"55">
55</option>
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56</option>
 <option style=3D"" value=3D"57">
57</option>
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58</option>
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59</option>
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<label class=3D"ss-q-item-label" style=3D"" for=3D"entry_1747608258">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Performance Status ECOG del Paciente <label style=3D"" aria-label=3D"(Campo obligatorio)" for=3D"itemView.getDomIdToLabel()">
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<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
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0</option>
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1</option>
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2</option>
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3</option>
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4</option>
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<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item  ss-scale" style=3D"margin:12px 0; overflow-x:auto" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" style=3D"" for=3D"entry_1716090865">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Escala Dolor EVA Actual </div>
<div class=3D"ss-q-help ss-secondary-text" style=3D"display:block; margin:.1em 0 .25em 0; color:#666" dir=3D"auto">
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0</label>
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1</label>
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2</label>
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3</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1421689035_5">
4</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1421689035_6">
5</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1421689035_7">
6</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1421689035_8">
7</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1421689035_9">
8</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1421689035_10">
9</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1421689035_11">
10</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr role=3D"radiogroup" style=3D"" aria-label=3D"Escala Dolor EVA Actual  Selecciona un valor en el intervalo de 0 a 10 .">
<td class=3D"ss-scalerow ss-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"aria-todo" aria-hidden=3D"true" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input name=3D"entry.1421689035" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1421689035_1" role=3D"radio" style=3D"" aria-label=3D"0" type=3D"radio" checked=3D"" value=3D"0">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input name=3D"entry.1421689035" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1421689035_2" role=3D"radio" style=3D"" aria-label=3D"1" type=3D"radio" value=3D"1">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input name=3D"entry.1421689035" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1421689035_3" role=3D"radio" style=3D"" aria-label=3D"2" type=3D"radio" value=3D"2">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input name=3D"entry.1421689035" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1421689035_4" role=3D"radio" style=3D"" aria-label=3D"3" type=3D"radio" value=3D"3">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input name=3D"entry.1421689035" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1421689035_5" role=3D"radio" style=3D"" aria-label=3D"4" type=3D"radio" value=3D"4">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input name=3D"entry.1421689035" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1421689035_6" role=3D"radio" style=3D"" aria-label=3D"5" type=3D"radio" value=3D"5">
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</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input name=3D"entry.1421689035" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1421689035_7" role=3D"radio" style=3D"" aria-label=3D"6" type=3D"radio" value=3D"6">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input name=3D"entry.1421689035" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1421689035_8" role=3D"radio" style=3D"" aria-label=3D"7" type=3D"radio" value=3D"7">
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<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input name=3D"entry.1421689035" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1421689035_9" role=3D"radio" style=3D"" aria-label=3D"8" type=3D"radio" value=3D"8">
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</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input name=3D"entry.1421689035" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1421689035_10" role=3D"radio" style=3D"" aria-label=3D"9" type=3D"radio" value=3D"9">
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</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input name=3D"entry.1421689035" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1421689035_11" role=3D"radio" style=3D"" aria-label=3D"10" type=3D"radio" value=3D"10">
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</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item  ss-scale" style=3D"margin:12px 0; overflow-x:auto" dir=3D"auto">
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<label class=3D"ss-q-item-label" style=3D"" for=3D"entry_2064050596">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Escala Dolor EVA M=E1ximo </div>
<div class=3D"ss-q-help ss-secondary-text" style=3D"display:block; margin:.1em 0 .25em 0; color:#666" dir=3D"auto">
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</label>
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<tbody>
<tr aria-hidden=3D"true" style=3D"">
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1244707512_1">
0</label>
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<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1244707512_2">
1</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1244707512_3">
2</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1244707512_4">
3</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1244707512_5">
4</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1244707512_6">
5</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1244707512_7">
6</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1244707512_8">
7</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1244707512_9">
8</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1244707512_10">
9</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" style=3D"display:block; padding:0.5em 0 .5em" for=3D"group_1244707512_11">
10</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr role=3D"radiogroup" style=3D"" aria-label=3D"Escala Dolor EVA M=E1ximo  Selecciona un valor en el intervalo de 0 a 10 .">
<td class=3D"ss-scalerow ss-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"aria-todo" aria-hidden=3D"true" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input name=3D"entry.1244707512" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1244707512_1" role=3D"radio" style=3D"" aria-label=3D"0" type=3D"radio" checked=3D"" value=3D"0">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input name=3D"entry.1244707512" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1244707512_2" role=3D"radio" style=3D"" aria-label=3D"1" type=3D"radio" value=3D"1">
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</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input name=3D"entry.1244707512" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1244707512_3" role=3D"radio" style=3D"" aria-label=3D"2" type=3D"radio" value=3D"2">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input name=3D"entry.1244707512" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1244707512_4" role=3D"radio" style=3D"" aria-label=3D"3" type=3D"radio" value=3D"3">
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</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input name=3D"entry.1244707512" disabled=3D"" class=3D"ss-q-radio" id=3D"group_1244707512_5" role=3D"radio" style=3D"" aria-label=3D"4" type=3D"radio" value=3D"4">
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17:32 Visita domiciliaria en conjunto con nutricionista . Antecedentes m=F3rbidos: Hipotiroidismo Alergia: Nueces cirug=EDa: refiere que cuando chica la operaron del pulm=F3n y coraz=F3n pero no sabe espec=EDficamente por que. adem=E1s operada de miop=EDa y estrabismo. Est=E1 se encuentra vigil, CLOTE, BEG, deambulando sin dificultad, EVA 0/10, pasa buena noche. se alimenta por v=EDa oral, con buena tolerancia, dieta com==FAn (porotos le hacen mal) se encuentra en compa=F1=EDa de su nieta. Diuresis (&#43;) Deposiciones (&#43;) calambre (-) precoldalgia (-) se encuentra en tratamiento con quimioterapia FI aprox: 15 de enero 2019 pr=F3xima 24 de abril 2019. Ultima quimio hace 24 horas bien tolerada An=EDmicamente estable, comunicativa, colaboradora control signos vitales PA: 122/76mmhg PAM: 91 FC: 84x' Sat: 96% T=B036.2=B0C, 11/04/2019 Peso 71kg esc=E1ner de abdomen con contraste ok En relaci=F3n a la alimentaci=F3n mala adherencia conclusi=F3n TOMOGRAFIA COMPUTARIZADA DE TORAX, ABDOMEN Y PELVIS CON CONTRASTE - control de neoplasia vasicular con compromiso de la via biliar, visualizado un cat=E9ter de via biliar de mayor di=E1metro bien posicionado y menos dilataci=F3n de la v=EDa biliar intrahep=E1tica - Desaparici=F3n de abscesos colangiticos descritos en el segmento II y VII hep=E1ticos. - persiste sin variaci=F3n la estenosis de las ramas izquierdas de la vena porta y arteria hep=E1tica. - Adenopat=EDa en el hilio hep=E1tico, estable. - Quiste simple cortical renal derecho, Bosniak 1 - Diverticulitis col=F3nica - disminuci=F3n del volumen pulmonar izq con discreto desplazamiento de las estructuras mediast=EDnicas hacia la izquierda. EXAMENES DE SANGRE 02/04/2019 eritrocitos 3.84 B. Cionjugada 0.15 hemoglobina 11.8 B. no conjugada 0.26 hematocrito 36.4 B. total 0.41 VCM 94.7 GOT/AST 27 HCM 30.7 GPT/ALT 36 CHCM 32.4 GGT 505 Neutr=F3filos 42.8 F. alcalinas 210 linfocitos 39.5 TP 12 monocitos 12 INR 0.90 plaqueta 597.000 CREA 0.83 VHS 26 </div>
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Cabeza: normocraneo,, correcci=F3n visual, uso de protesis dental sup y inf cuello: sin adenopat=EDas, sin masas palpables, m=F3vil t=F3rax: sim=E9trico, sin masas palpables Abdomen: Blando , depresible, indoloro, cicatriz quelode por cirug=EDa Extremidades: m=F3viles, sim=E9tricas, sin signos TVP, edema (&#43;&#43;&#43;), pulsos (&#43;) Mucosas: hidratadas, normocoloreadas genitales: femeninos sanos Piel: indemne, normocoloreada</div>
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CA vesicula ET IV &#43; Metastasis peritoneal</div>
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Adherencia a tratamiento farmacol=F3gico y alimentario hidrataci=F3n cuidados personales en caso de complicaciones acudir al servicio de urgencia Quimioterapia cada 2 semanas en Santiago en la FALP Mantener pies en alto</div>
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Medicamentos Indicados </div>
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Tramal 50mg c/12hrs Dipirona 300mg 1c/8hrs Lactulosa 20cc SOS Dislep 25mg 1c/8 hrs Viadil compuesto 30gotas x d=CDa Nexium 40mg 1 x d=EDa Domperidona 10mg 1c/12 hrs Tramadol gts 15 SOS adem=E1s se encuentra tomando terapia alternativa &quot;alacr=E1n azul&quot; cada 6 horas</div>
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</div>
<br>
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Fecha aproximada del Pr=F3ximo Control con usted </div>
<div class=3D"ss-q-help ss-secondary-text" style=3D"display:block; margin:.1em 0 .25em 0; color:#666" dir=3D"auto">
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<div class=3D"ss-q-date" role=3D"group" style=3D"" aria-label=3D"Fecha aproximada del Pr=F3ximo Control con usted  ">
<div class=3D"ss-datetime-box goog-inline-block" role=3D"group" style=3D"border:1px solid #dcdcdc; margin-right:2em; min-height:32px; padding-left:3px; vertical-align:middle; margin:4px 3px; display:inline-block">
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<option style=3D"" value=3D"">
D=EDa</option>
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1</option>
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2</option>
<option style=3D"" value=3D"3">
3</option>
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4</option>
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5</option>
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6</option>
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7</option>
<option style=3D"" value=3D"8">
8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
<option style=3D"" value=3D"22">
22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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Mes</option>
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enero</option>
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febrero</option>
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marzo</option>
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abril</option>
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mayo</option>
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junio</option>
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julio</option>
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agosto</option>
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septiembre</option>
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octubre</option>
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noviembre</option>
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diciembre</option>
</select>
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A=F1o</option>
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1896</option>
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1897</option>
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1898</option>
 <option style=3D"" value=3D"1899">
1899</option>
 <option style=3D"" value=3D"1900">
1900</option>
 <option style=3D"" value=3D"1901">
1901</option>
 <option style=3D"" value=3D"1902">
1902</option>
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1903</option>
 <option style=3D"" value=3D"1904">
1904</option>
 <option style=3D"" value=3D"1905">
1905</option>
 <option style=3D"" value=3D"1906">
1906</option>
 <option style=3D"" value=3D"1907">
1907</option>
 <option style=3D"" value=3D"1908">
1908</option>
 <option style=3D"" value=3D"1909">
1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
 <option style=3D"" value=3D"1918">
1918</option>
 <option style=3D"" value=3D"1919">
1919</option>
 <option style=3D"" value=3D"1920">
1920</option>
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1921</option>
 <option style=3D"" value=3D"1922">
1922</option>
 <option style=3D"" value=3D"1923">
1923</option>
 <option style=3D"" value=3D"1924">
1924</option>
 <option style=3D"" value=3D"1925">
1925</option>
 <option style=3D"" value=3D"1926">
1926</option>
 <option style=3D"" value=3D"1927">
1927</option>
 <option style=3D"" value=3D"1928">
1928</option>
 <option style=3D"" value=3D"1929">
1929</option>
 <option style=3D"" value=3D"1930">
1930</option>
 <option style=3D"" value=3D"1931">
1931</option>
 <option style=3D"" value=3D"1932">
1932</option>
 <option style=3D"" value=3D"1933">
1933</option>
 <option style=3D"" value=3D"1934">
1934</option>
 <option style=3D"" value=3D"1935">
1935</option>
 <option style=3D"" value=3D"1936">
1936</option>
 <option style=3D"" value=3D"1937">
1937</option>
 <option style=3D"" value=3D"1938">
1938</option>
 <option style=3D"" value=3D"1939">
1939</option>
 <option style=3D"" value=3D"1940">
1940</option>
 <option style=3D"" value=3D"1941">
1941</option>
 <option style=3D"" value=3D"1942">
1942</option>
 <option style=3D"" value=3D"1943">
1943</option>
 <option style=3D"" value=3D"1944">
1944</option>
 <option style=3D"" value=3D"1945">
1945</option>
 <option style=3D"" value=3D"1946">
1946</option>
 <option style=3D"" value=3D"1947">
1947</option>
 <option style=3D"" value=3D"1948">
1948</option>
 <option style=3D"" value=3D"1949">
1949</option>
 <option style=3D"" value=3D"1950">
1950</option>
 <option style=3D"" value=3D"1951">
1951</option>
 <option style=3D"" value=3D"1952">
1952</option>
 <option style=3D"" value=3D"1953">
1953</option>
 <option style=3D"" value=3D"1954">
1954</option>
 <option style=3D"" value=3D"1955">
1955</option>
 <option style=3D"" value=3D"1956">
1956</option>
 <option style=3D"" value=3D"1957">
1957</option>
 <option style=3D"" value=3D"1958">
1958</option>
 <option style=3D"" value=3D"1959">
1959</option>
 <option style=3D"" value=3D"1960">
1960</option>
 <option style=3D"" value=3D"1961">
1961</option>
 <option style=3D"" value=3D"1962">
1962</option>
 <option style=3D"" value=3D"1963">
1963</option>
 <option style=3D"" value=3D"1964">
1964</option>
 <option style=3D"" value=3D"1965">
1965</option>
 <option style=3D"" value=3D"1966">
1966</option>
 <option style=3D"" value=3D"1967">
1967</option>
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1968</option>
 <option style=3D"" value=3D"1969">
1969</option>
 <option style=3D"" value=3D"1970">
1970</option>
 <option style=3D"" value=3D"1971">
1971</option>
 <option style=3D"" value=3D"1972">
1972</option>
 <option style=3D"" value=3D"1973">
1973</option>
 <option style=3D"" value=3D"1974">
1974</option>
 <option style=3D"" value=3D"1975">
1975</option>
 <option style=3D"" value=3D"1976">
1976</option>
 <option style=3D"" value=3D"1977">
1977</option>
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1978</option>
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1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
 <option style=3D"" value=3D"1992">
1992</option>
 <option style=3D"" value=3D"1993">
1993</option>
 <option style=3D"" value=3D"1994">
1994</option>
 <option style=3D"" value=3D"1995">
1995</option>
 <option style=3D"" value=3D"1996">
1996</option>
 <option style=3D"" value=3D"1997">
1997</option>
 <option style=3D"" value=3D"1998">
1998</option>
 <option style=3D"" value=3D"1999">
1999</option>
 <option style=3D"" value=3D"2000">
2000</option>
 <option style=3D"" value=3D"2001">
2001</option>
 <option style=3D"" value=3D"2002">
2002</option>
 <option style=3D"" value=3D"2003">
2003</option>
 <option style=3D"" value=3D"2004">
2004</option>
 <option style=3D"" value=3D"2005">
2005</option>
 <option style=3D"" value=3D"2006">
2006</option>
 <option style=3D"" value=3D"2007">
2007</option>
 <option style=3D"" value=3D"2008">
2008</option>
 <option style=3D"" value=3D"2009">
2009</option>
 <option style=3D"" value=3D"2010">
2010</option>
 <option style=3D"" value=3D"2011">
2011</option>
 <option style=3D"" value=3D"2012">
2012</option>
 <option style=3D"" value=3D"2013">
2013</option>
 <option style=3D"" value=3D"2014">
2014</option>
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2015</option>
 <option style=3D"" value=3D"2016">
2016</option>
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2017</option>
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2018</option>
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2019</option>
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2020</option>
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2021</option>
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2022</option>
 <option style=3D"" value=3D"2023">
2023</option>
 <option style=3D"" value=3D"2024">
2024</option>
 <option style=3D"" value=3D"2025">
2025</option>
 <option style=3D"" value=3D"2026">
2026</option>
 <option style=3D"" value=3D"2027">
2027</option>
 <option style=3D"" value=3D"2028">
2028</option>
 <option style=3D"" value=3D"2029">
2029</option>
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2030</option>
 <option style=3D"" value=3D"2031">
2031</option>
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2032</option>
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2033</option>
 <option style=3D"" value=3D"2034">
2034</option>
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2035</option>
 <option style=3D"" value=3D"2036">
2036</option>
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2037</option>
 <option style=3D"" value=3D"2038">
2038</option>
 <option style=3D"" value=3D"2039">
2039</option>
 <option style=3D"" value=3D"2040">
2040</option>
 <option style=3D"" value=3D"2041">
2041</option>
 <option style=3D"" value=3D"2042">
2042</option>
 <option style=3D"" value=3D"2043">
2043</option>
 <option style=3D"" value=3D"2044">
2044</option>
 <option style=3D"" value=3D"2045">
2045</option>
 <option style=3D"" value=3D"2046">
2046</option>
 <option style=3D"" value=3D"2047">
2047</option>
 <option style=3D"" value=3D"2048">
2048</option>
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2049</option>
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2050</option>
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2051</option>
 <option style=3D"" value=3D"2052">
2052</option>
 <option style=3D"" value=3D"2053">
2053</option>
 <option style=3D"" value=3D"2054">
2054</option>
 <option style=3D"" value=3D"2055">
2055</option>
 <option style=3D"" value=3D"2056">
2056</option>
 <option style=3D"" value=3D"2057">
2057</option>
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2058</option>
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2059</option>
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2060</option>
 <option style=3D"" value=3D"2061">
2061</option>
 <option style=3D"" value=3D"2062">
2062</option>
 <option style=3D"" value=3D"2063">
2063</option>
 <option style=3D"" value=3D"2064">
2064</option>
 <option style=3D"" value=3D"2065">
2065</option>
 <option style=3D"" value=3D"2066">
2066</option>
 <option style=3D"" value=3D"2067">
2067</option>
 <option style=3D"" value=3D"2068">
2068</option>
 <option style=3D"" value=3D"2069">
2069</option>
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</div>
</div>
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<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item  ss-text" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" style=3D"" for=3D"entry_74766472">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Tratamiento Realizado (si corresponde) </div>
<div class=3D"ss-q-help ss-secondary-text" style=3D"display:block; margin:.1em 0 .25em 0; color:#666" dir=3D"auto">
</div>
</label>
<div class=3D"ss-q-text" style=3D"background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%" dir=3D"auto">
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<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div class=3D"ss-item  ss-checkbox" style=3D"margin:12px 0" dir=3D"auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" style=3D"" for=3D"entry_1219705969">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Derivaci=F3n a otro Prestador Domiciliario </div>
<div class=3D"ss-q-help ss-secondary-text" style=3D"display:block; margin:.1em 0 .25em 0; color:#666" dir=3D"auto">
S=F3lo llene esta secci=F3n si es m=E9dico y solicita la visita de otro prestador del equipo</div>
</label>
<ul class=3D"ss-choices" role=3D"group" style=3D"list-style:none; padding:0; margin:.5em 0 0" aria-label=3D"Derivaci=F3n a otro Prestador Domiciliario S=F3lo llene esta secci=F3n si es m=E9dico y solicita la visita de otro prestador del equipo ">
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<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input name=3D"entry.503039759" disabled=3D"" class=3D"ss-q-checkbox" id=3D"group_503039759_1" role=3D"checkbox" style=3D"" type==3D"checkbox" value=3D"ENFERMERA">
</span>
<span class=3D"ss-choice-label" style=3D"">
ENFERMERA</span>
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</li>
<li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input name=3D"entry.503039759" disabled=3D"" class=3D"ss-q-checkbox" id=3D"group_503039759_2" role=3D"checkbox" style=3D"" type==3D"checkbox" value=3D"TENS">
</span>
<span class=3D"ss-choice-label" style=3D"">
TENS</span>
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</li>
<li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input name=3D"entry.503039759" disabled=3D"" class=3D"ss-q-checkbox" id=3D"group_503039759_3" role=3D"checkbox" style=3D"" type==3D"checkbox" value=3D"NUTRICIONISTA">
</span>
<span class=3D"ss-choice-label" style=3D"">
NUTRICIONISTA</span>
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<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input name=3D"entry.503039759" disabled=3D"" class=3D"ss-q-checkbox" id=3D"group_503039759_4" role=3D"checkbox" style=3D"" type==3D"checkbox" value=3D"KINESIOLOGO">
</span>
<span class=3D"ss-choice-label" style=3D"">
KINESIOLOGO</span>
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<li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input name=3D"entry.503039759" disabled=3D"" class=3D"ss-q-checkbox" id=3D"group_503039759_5" role=3D"checkbox" style=3D"" type==3D"checkbox" value=3D"PSICOLOGO">
</span>
<span class=3D"ss-choice-label" style=3D"">
PSICOLOGO</span>
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