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<b>
De:</b>
 Formularios de Google &lt;forms-receipts-noreply@google.com&gt;<br>
<b>
Enviado:</b>
 s=E1bado, 22 de junio de 2019 3:22 a. m.<br>
<b>
Para:</b>
 katherine.mcortes.md@outlook.com<br>
<b>
Asunto:</b>
 Registro de Atenci=F3n Domiciliaria Oncovida</font>
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&nbsp;</div>
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<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%" role=3D"presentation" style=3D"background-color:rgb(38,4,154)">
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<img alt=3D"Formularios de Google" height==3D"26px" width=3D"143px" style=3D"display:inline-block; margin:0; vertical-align:middle" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
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</tbody>
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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 align=3D"center" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%" role=3D"presentation" style=3D"background-color:#fff">
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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>
</div>
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<tr height=3D"12px">
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<div style=3D"font-size:13px; line-height:18px; color:#424242">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"ss-form-container" style=3D"">
<div class=3D"ss-form-heading" style=3D"">
<h1 class=3D"ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
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 action=3D"" method=3D"GET" id=3D"ss-form" style=3D"">
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<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" for=3D"emailAddress" style=3D"">
<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 for=3D"emailAddress" aria-label==3D"(Campo obligatorio)" style=3D"">
</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" 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%">
katherine.mcortes.md@outlook.com</div>
</div>
</div>
</div>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style==3D"margin:12px 0; max-width:100%">
<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 class=3D"ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ">
</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0">
<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" dir=3D"auto" style=3D"white-space:pre-wrap; word-wrap:break-word">
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 dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<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" for=3D"entry_579114469" style=3D"">
<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 for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</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" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-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%">
KATHERINE MORALES </div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<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" for=3D"entry_1276273985" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
RUT <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</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" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
RUT con Gui=F3n y D=EDgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"ss-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%">
25184204-3</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-select" style=3D"margin:12px 0">
<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" for=3D"entry_133691676" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Tipo <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</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" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
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" aria-label=3D"Tipo Si asisten m=E1s de 1 prestador simult=E1neamente, cada uno debe hacer un registro independiente " style=3D"">
<option value=3D"" style=3D"">
</option>
 <option value=3D"MEDICO" disabled=3D"" selected=3D"" style=3D"">
MEDICO</option>
<option value=3D"ENFERMERA/O" disabled=3D"" style=3D"">
ENFERMERA/O</option>
 <option value=3D"TENS" disabled=3D"" style=3D"">
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled=3D"" style=3D"">
KINESIOLOGA/O</option>
<option value=3D"PSICOLOGO" disabled=3D"" style=3D"">
PSICOLOGO</option>
 <option value=3D"NUTRICIONISTA" disabled=3D"" style=3D"">
NUTRICIONISTA</option>
</select>
 </div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style==3D"margin:12px 0; max-width:100%">
<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 class=3D"ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" 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 dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0">
<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" dir=3D"auto" style=3D"white-space:pre-wrap; word-wrap:break-word">
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 dir=3D"auto" class=3D"ss-item  ss-section-header" style=3D"margin:12px 0">
<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 dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<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" for=3D"entry_823811303" style=3D"">
<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 for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</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" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
RUT con Gui=F3n y D=EDgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"ss-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%">
13447718-7</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<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" for=3D"entry_1959365839" style=3D"">
<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 for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</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" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-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%">
SONIA ARAOS</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-select" style=3D"margin:12px 0">
<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" for=3D"entry_545002227" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Previsi=F3n <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</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" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<select name=3D"entry.545002227" disabled=3D"" id=3D"entry_545002227" aria-label=3D"Previsi=F3n  " style=3D"">
<option value=3D"" style=3D"">
</option>
 <option value=3D"BANMEDICA" disabled=3D"" style=3D"">
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled=3D"" style=3D"">
CAPREDENA</option>
 <option value=3D"COLMENA" disabled=3D"" selected=3D"" style=3D"">
COLMENA</option>
 <option value=3D"CONSALUD" disabled=3D"" style=3D"">
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled=3D"" style=3D"">
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled=3D"" style=3D"">
DIPRECA</option>
<option value=3D"FONASA" disabled=3D"" style=3D"">
FONASA</option>
 <option value=3D"FUNDACION" disabled=3D"" style=3D"">
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled=3D"" style==3D"">
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled=3D"" style=3D"">
NUEVA MASVIDA</option>
<option value=3D"VIDATRES" disabled=3D"" style=3D"">
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled=3D"" style=3D"">
PARTICULAR</option>
</select>
 </div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<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" for=3D"entry_1900161356" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Ciudad <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</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" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-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%">
ARICA</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<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" for=3D"entry_1298871758" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Comuna <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</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" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-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%">
ARICA</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style==3D"margin:12px 0; max-width:100%">
<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 class=3D"ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" 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 dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0">
<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" dir=3D"auto" style=3D"white-space:pre-wrap; word-wrap:break-word">
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 dir=3D"auto" class=3D"ss-item ss-item-required ss-radio" style=3D"margin:12px 0">
<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" for=3D"entry_2073233714" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Tipo de Atenci=F3n <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</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" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<ul class=3D"ss-choices" role=3D"radiogroup" aria-label=3D"Tipo de Atenci==F3n  " style=3D"list-style:none; padding:0; margin:.5em 0 0">
<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 type=3D"radio" name=3D"entry.1222378237" disabled=3D"" checked=3D"" value=3D"Domicilio" id=3D"group_1222378237_1" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"Domicilio" style=3D"">
</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 type=3D"radio" name=3D"entry.1222378237" disabled=3D"" value=3D"Ambulatorio" id=3D"group_1222378237_2" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"Ambulatorio" style=3D"">
</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 dir=3D"auto" class=3D"ss-item ss-item-required ss-date" style=3D"margin:12px 0">
<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" for=3D"entry_1705849412" style=3D"">
<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 for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</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" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-date" role=3D"group" aria-label=3D"Fecha de la Atenci=F3n  " style=3D"">
<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" aria-label=3D"D=EDa del mes" style=3D"">
<option value=3D"" style=3D"">
D=EDa</option>
 <option value=3D"1" style=3D"">
1</option>
 <option value=3D"2" style=3D"">
2</option>
<option value=3D"3" style=3D"">
3</option>
 <option value=3D"4" style=3D"">
4</option>
 <option value=3D"5" style=3D"">
5</option>
 <option value=3D"6" style=3D"">
6</option>
 <option value=3D"7" style=3D"">
7</option>
<option value=3D"8" style=3D"">
8</option>
 <option value=3D"9" style=3D"">
9</option>
 <option value=3D"10" style=3D"">
10</option>
 <option value=3D"11" style=3D"">
11</option>
 <option value=3D"12" style=3D"">
12</option>
 <option value=3D"13" style=3D"">
13</option>
 <option value=3D"14" style=3D"">
14</option>
<option value=3D"15" style=3D"">
15</option>
 <option value=3D"16" style=3D"">
16</option>
 <option value=3D"17" style=3D"">
17</option>
 <option value=3D"18" style=3D"">
18</option>
 <option value=3D"19" style=3D"">
19</option>
 <option value=3D"20" style=3D"">
20</option>
 <option value=3D"21" selected=3D"" style=3D"">
21</option>
 <option value=3D"22" style=3D"">
22</option>
 <option value=3D"23" style=3D"">
23</option>
 <option value=3D"24" style=3D"">
24</option>
 <option value=3D"25" style=3D"">
25</option>
<option value=3D"26" style=3D"">
26</option>
 <option value=3D"27" style=3D"">
27</option>
 <option value=3D"28" style=3D"">
28</option>
 <option value=3D"29" style=3D"">
29</option>
 <option value=3D"30" style=3D"">
30</option>
 <option value=3D"31" style=3D"">
31</option>
</select>
 <select name=3D"entry.1705849412_month" disabled=3D"" class=3D"ss-month-dropdown" id=3D"entry.1705849412_month" aria-label=3D"Mes" style=3D"">
<option value=3D"" style=3D"">
Mes</option>
 <option value=3D"1" style=3D"">
enero</option>
 <option value=3D"2" style=3D"">
febrero</option>
 <option value=3D"3" style=3D"">
marzo</option>
 <option value=3D"4" style=3D"">
abril</option>
 <option value=3D"5" style=3D"">
mayo</option>
 <option value==3D"6" selected=3D"" style=3D"">
junio</option>
 <option value=3D"7" style=3D"">
julio</option>
 <option value==3D"8" style=3D"">
agosto</option>
 <option value=3D"9" style=3D"">
septiembre</option>
 <option value=3D"10" style=3D"">
octubre</option>
 <option value=3D"11" style=3D"">
noviembre</option>
 <option value=3D"12" style=3D"">
diciembre</option>
</select>
 <select name=3D"entry.1705849412_year" disabled=3D"" id=3D"entry.1705849412_year" aria-label=3D"A=F1o" style=3D"">
<option value=3D"" style=3D"">
A=F1o</option>
 <option value=3D"1896" style=3D"">
1896</option>
 <option value=3D"1897" style=3D"">
1897</option>
 <option value=3D"1898" style=3D"">
1898</option>
 <option value=3D"1899" style=3D"">
1899</option>
 <option value=3D"1900" style=3D"">
1900</option>
 <option value=3D"1901" style=3D"">
1901</option>
 <option value=3D"1902" style=3D"">
1902</option>
 <option value=3D"1903" style=3D"">
1903</option>
 <option value=3D"1904" style=3D"">
1904</option>
 <option value=3D"1905" style=3D"">
1905</option>
 <option value=3D"1906" style=3D"">
1906</option>
 <option value=3D"1907" style=3D"">
1907</option>
 <option value=3D"1908" style=3D"">
1908</option>
 <option value=3D"1909" style=3D"">
1909</option>
 <option value=3D"1910" style=3D"">
1910</option>
 <option value=3D"1911" style=3D"">
1911</option>
 <option value=3D"1912" style=3D"">
1912</option>
 <option value=3D"1913" style=3D"">
1913</option>
 <option value=3D"1914" style=3D"">
1914</option>
 <option value=3D"1915" style=3D"">
1915</option>
 <option value=3D"1916" style=3D"">
1916</option>
 <option value=3D"1917" style=3D"">
1917</option>
 <option value=3D"1918" style=3D"">
1918</option>
 <option value=3D"1919" style=3D"">
1919</option>
 <option value=3D"1920" style=3D"">
1920</option>
 <option value=3D"1921" style=3D"">
1921</option>
 <option value=3D"1922" style=3D"">
1922</option>
 <option value=3D"1923" style=3D"">
1923</option>
 <option value=3D"1924" style=3D"">
1924</option>
 <option value=3D"1925" style=3D"">
1925</option>
 <option value=3D"1926" style=3D"">
1926</option>
 <option value=3D"1927" style=3D"">
1927</option>
 <option value=3D"1928" style=3D"">
1928</option>
 <option value=3D"1929" style=3D"">
1929</option>
 <option value=3D"1930" style=3D"">
1930</option>
 <option value=3D"1931" style=3D"">
1931</option>
 <option value=3D"1932" style=3D"">
1932</option>
 <option value=3D"1933" style=3D"">
1933</option>
 <option value=3D"1934" style=3D"">
1934</option>
 <option value=3D"1935" style=3D"">
1935</option>
 <option value=3D"1936" style=3D"">
1936</option>
 <option value=3D"1937" style=3D"">
1937</option>
 <option value=3D"1938" style=3D"">
1938</option>
 <option value=3D"1939" style=3D"">
1939</option>
 <option value=3D"1940" style=3D"">
1940</option>
 <option value=3D"1941" style=3D"">
1941</option>
 <option value=3D"1942" style=3D"">
1942</option>
 <option value=3D"1943" style=3D"">
1943</option>
 <option value=3D"1944" style=3D"">
1944</option>
 <option value=3D"1945" style=3D"">
1945</option>
 <option value=3D"1946" style=3D"">
1946</option>
 <option value=3D"1947" style=3D"">
1947</option>
 <option value=3D"1948" style=3D"">
1948</option>
 <option value=3D"1949" style=3D"">
1949</option>
 <option value=3D"1950" style=3D"">
1950</option>
 <option value=3D"1951" style=3D"">
1951</option>
 <option value=3D"1952" style=3D"">
1952</option>
 <option value=3D"1953" style=3D"">
1953</option>
 <option value=3D"1954" style=3D"">
1954</option>
 <option value=3D"1955" style=3D"">
1955</option>
 <option value=3D"1956" style=3D"">
1956</option>
 <option value=3D"1957" style=3D"">
1957</option>
 <option value=3D"1958" style=3D"">
1958</option>
 <option value=3D"1959" style=3D"">
1959</option>
 <option value=3D"1960" style=3D"">
1960</option>
 <option value=3D"1961" style=3D"">
1961</option>
 <option value=3D"1962" style=3D"">
1962</option>
 <option value=3D"1963" style=3D"">
1963</option>
 <option value=3D"1964" style=3D"">
1964</option>
 <option value=3D"1965" style=3D"">
1965</option>
 <option value=3D"1966" style=3D"">
1966</option>
 <option value=3D"1967" style=3D"">
1967</option>
 <option value=3D"1968" style=3D"">
1968</option>
 <option value=3D"1969" style=3D"">
1969</option>
 <option value=3D"1970" style=3D"">
1970</option>
 <option value=3D"1971" style=3D"">
1971</option>
 <option value=3D"1972" style=3D"">
1972</option>
 <option value=3D"1973" style=3D"">
1973</option>
 <option value=3D"1974" style=3D"">
1974</option>
 <option value=3D"1975" style=3D"">
1975</option>
 <option value=3D"1976" style=3D"">
1976</option>
 <option value=3D"1977" style=3D"">
1977</option>
 <option value=3D"1978" style=3D"">
1978</option>
 <option value=3D"1979" style=3D"">
1979</option>
 <option value=3D"1980" style=3D"">
1980</option>
 <option value=3D"1981" style=3D"">
1981</option>
 <option value=3D"1982" style=3D"">
1982</option>
 <option value=3D"1983" style=3D"">
1983</option>
 <option value=3D"1984" style=3D"">
1984</option>
 <option value=3D"1985" style=3D"">
1985</option>
 <option value=3D"1986" style=3D"">
1986</option>
 <option value=3D"1987" style=3D"">
1987</option>
 <option value=3D"1988" style=3D"">
1988</option>
 <option value=3D"1989" style=3D"">
1989</option>
 <option value=3D"1990" style=3D"">
1990</option>
 <option value=3D"1991" style=3D"">
1991</option>
 <option value=3D"1992" style=3D"">
1992</option>
 <option value=3D"1993" style=3D"">
1993</option>
 <option value=3D"1994" style=3D"">
1994</option>
 <option value=3D"1995" style=3D"">
1995</option>
 <option value=3D"1996" style=3D"">
1996</option>
 <option value=3D"1997" style=3D"">
1997</option>
 <option value=3D"1998" style=3D"">
1998</option>
 <option value=3D"1999" style=3D"">
1999</option>
 <option value=3D"2000" style=3D"">
2000</option>
 <option value=3D"2001" style=3D"">
2001</option>
 <option value=3D"2002" style=3D"">
2002</option>
 <option value=3D"2003" style=3D"">
2003</option>
 <option value=3D"2004" style=3D"">
2004</option>
 <option value=3D"2005" style=3D"">
2005</option>
 <option value=3D"2006" style=3D"">
2006</option>
 <option value=3D"2007" style=3D"">
2007</option>
 <option value=3D"2008" style=3D"">
2008</option>
 <option value=3D"2009" style=3D"">
2009</option>
 <option value=3D"2010" style=3D"">
2010</option>
 <option value=3D"2011" style=3D"">
2011</option>
 <option value=3D"2012" style=3D"">
2012</option>
 <option value=3D"2013" style=3D"">
2013</option>
 <option value=3D"2014" style=3D"">
2014</option>
 <option value=3D"2015" style=3D"">
2015</option>
 <option value=3D"2016" style=3D"">
2016</option>
 <option value=3D"2017" style=3D"">
2017</option>
 <option value=3D"2018" style=3D"">
2018</option>
 <option value=3D"2019" selected=3D"" style=3D"">
2019</option>
 <option value=3D"2020" style=3D"">
2020</option>
 <option value=3D"2021" style=3D"">
2021</option>
 <option value=3D"2022" style=3D"">
2022</option>
 <option value=3D"2023" style=3D"">
2023</option>
 <option value=3D"2024" style=3D"">
2024</option>
 <option value=3D"2025" style=3D"">
2025</option>
 <option value=3D"2026" style=3D"">
2026</option>
 <option value=3D"2027" style=3D"">
2027</option>
 <option value=3D"2028" style=3D"">
2028</option>
 <option value=3D"2029" style=3D"">
2029</option>
 <option value=3D"2030" style=3D"">
2030</option>
 <option value=3D"2031" style=3D"">
2031</option>
 <option value=3D"2032" style=3D"">
2032</option>
 <option value=3D"2033" style=3D"">
2033</option>
 <option value=3D"2034" style=3D"">
2034</option>
 <option value=3D"2035" style=3D"">
2035</option>
 <option value=3D"2036" style=3D"">
2036</option>
 <option value=3D"2037" style=3D"">
2037</option>
 <option value=3D"2038" style=3D"">
2038</option>
 <option value=3D"2039" style=3D"">
2039</option>
 <option value=3D"2040" style=3D"">
2040</option>
 <option value=3D"2041" style=3D"">
2041</option>
 <option value=3D"2042" style=3D"">
2042</option>
 <option value=3D"2043" style=3D"">
2043</option>
 <option value=3D"2044" style=3D"">
2044</option>
 <option value=3D"2045" style=3D"">
2045</option>
 <option value=3D"2046" style=3D"">
2046</option>
 <option value=3D"2047" style=3D"">
2047</option>
 <option value=3D"2048" style=3D"">
2048</option>
 <option value=3D"2049" style=3D"">
2049</option>
 <option value=3D"2050" style=3D"">
2050</option>
 <option value=3D"2051" style=3D"">
2051</option>
 <option value=3D"2052" style=3D"">
2052</option>
 <option value=3D"2053" style=3D"">
2053</option>
 <option value=3D"2054" style=3D"">
2054</option>
 <option value=3D"2055" style=3D"">
2055</option>
 <option value=3D"2056" style=3D"">
2056</option>
 <option value=3D"2057" style=3D"">
2057</option>
 <option value=3D"2058" style=3D"">
2058</option>
 <option value=3D"2059" style=3D"">
2059</option>
 <option value=3D"2060" style=3D"">
2060</option>
 <option value=3D"2061" style=3D"">
2061</option>
 <option value=3D"2062" style=3D"">
2062</option>
 <option value=3D"2063" style=3D"">
2063</option>
 <option value=3D"2064" style=3D"">
2064</option>
 <option value=3D"2065" style=3D"">
2065</option>
 <option value=3D"2066" style=3D"">
2066</option>
 <option value=3D"2067" style=3D"">
2067</option>
 <option value=3D"2068" style=3D"">
2068</option>
 <option value=3D"2069" style=3D"">
2069</option>
</select>
 </div>
</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-time" style=3D"margin:12px 0; font:inherit">
<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" for=3D"entry_206244955" style=3D"">
<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 for=3D"itemView.getDomIdToLabel()" aria-label==3D"(Campo obligatorio)" style=3D"">
</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" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-time" style=3D"">
<div class=3D"ss-datetime-box goog-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=3D"" id=3D"entry.206244955_hour" aria-label=3D"Hora" style=3D"">
<option value=3D"" style=3D"">
h</option>
 <option value=3D"00" style=3D"">
00</option>
 <option value=3D"01" style=3D"">
01</option>
 <option value=3D"02" style=3D"">
02</option>
 <option value=3D"03" style=3D"">
03</option>
<option value=3D"04" style=3D"">
04</option>
 <option value=3D"05" style=3D"">
05</option>
 <option value=3D"06" style=3D"">
06</option>
 <option value=3D"07" style=3D"">
07</option>
 <option value=3D"08" style=3D"">
08</option>
 <option value=3D"09" style=3D"">
09</option>
 <option value=3D"10" style=3D"">
10</option>
<option value=3D"11" style=3D"">
11</option>
 <option value=3D"12" style=3D"">
12</option>
 <option value=3D"13" style=3D"">
13</option>
 <option value=3D"14" style=3D"">
14</option>
 <option value=3D"15" style=3D"">
15</option>
 <option value=3D"16" style=3D"">
16</option>
 <option value=3D"17" style=3D"">
17</option>
<option value=3D"18" style=3D"">
18</option>
 <option value=3D"19" style=3D"">
19</option>
 <option value=3D"20" selected=3D"" style=3D"">
20</option>
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17</option>
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18</option>
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20</option>
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<option value=3D"29" style=3D"">
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>
<option value=3D"36" style=3D"">
36</option>
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37</option>
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38</option>
 <option value=3D"39" style=3D"">
39</option>
 <option value=3D"40" style=3D"">
40</option>
 <option value=3D"41" style=3D"">
41</option>
 <option value=3D"42" style=3D"">
42</option>
<option value=3D"43" style=3D"">
43</option>
 <option value=3D"44" style=3D"">
44</option>
 <option value=3D"45" style=3D"">
45</option>
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46</option>
 <option value=3D"47" style=3D"">
47</option>
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48</option>
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49</option>
<option value=3D"50" style=3D"">
50</option>
 <option value=3D"51" style=3D"">
51</option>
 <option value=3D"52" style=3D"">
52</option>
 <option value=3D"53" style=3D"">
53</option>
 <option value=3D"54" style=3D"">
54</option>
 <option value=3D"55" style=3D"">
55</option>
 <option value=3D"56" style=3D"">
56</option>
<option value=3D"57" style=3D"">
57</option>
 <option value=3D"58" style=3D"">
58</option>
 <option value=3D"59" style=3D"">
59</option>
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<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
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Performance Status ECOG del Paciente <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
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<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
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Escala Dolor EVA Actual </div>
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3</label>
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4</label>
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5</label>
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6</label>
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7</label>
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8</label>
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9</label>
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10</label>
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<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
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Escala Dolor EVA M=E1ximo </div>
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</td>
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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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<label class=3D"ss-scalenumber" for=3D"group_1244707512_5" style=3D"display:block; padding:0.5em 0 .5em">
4</label>
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5</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" for=3D"group_1244707512_7" style=3D"display:block; padding:0.5em 0 .5em">
6</label>
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<label class=3D"ss-scalenumber" for=3D"group_1244707512_8" style=3D"display:block; padding:0.5em 0 .5em">
7</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" for=3D"group_1244707512_9" style=3D"display:block; padding:0.5em 0 .5em">
8</label>
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<label class=3D"ss-scalenumber" for=3D"group_1244707512_10" style=3D"display:block; padding:0.5em 0 .5em">
9</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" for=3D"group_1244707512_11" style=3D"display:block; padding:0.5em 0 .5em">
10</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
</td>
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<tr role=3D"radiogroup" aria-label=3D"Escala Dolor EVA M=E1ximo  Selecciona un valor en el intervalo de 0 a 10 ." style=3D"">
<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 aria-hidden=3D"true" class=3D"aria-todo" 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">
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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"">
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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"">
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</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"">
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</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 type=3D"radio" name==3D"entry.1244707512" disabled=3D"" value=3D"6" id=3D"group_1244707512_7" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"6" 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 type=3D"radio" name==3D"entry.1244707512" disabled=3D"" value=3D"7" id=3D"group_1244707512_8" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"7" 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 type=3D"radio" name==3D"entry.1244707512" disabled=3D"" value=3D"8" id=3D"group_1244707512_9" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"8" 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 type=3D"radio" name==3D"entry.1244707512" disabled=3D"" value=3D"9" id=3D"group_1244707512_10" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"9" 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 type=3D"radio" name==3D"entry.1244707512" disabled=3D"" value=3D"10" id=3D"group_1244707512_11" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"10" style=3D"">
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<td class=3D"ss-scalerow ss-rightlabel" aria-hidden=3D"true" style=3D"text-align:left; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em; padding-right:0">
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<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Escala Dolor EVA M=EDnimo </div>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
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<label class=3D"ss-scalenumber" for=3D"group_853118630_1" style=3D"display:block; padding:0.5em 0 .5em">
0</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" for=3D"group_853118630_2" style=3D"display:block; padding:0.5em 0 .5em">
1</label>
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2</label>
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<label class=3D"ss-scalenumber" for=3D"group_853118630_4" style=3D"display:block; padding:0.5em 0 .5em">
3</label>
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<label class=3D"ss-scalenumber" for=3D"group_853118630_5" style=3D"display:block; padding:0.5em 0 .5em">
4</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" for=3D"group_853118630_6" style=3D"display:block; padding:0.5em 0 .5em">
5</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" for=3D"group_853118630_7" style=3D"display:block; padding:0.5em 0 .5em">
6</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" for=3D"group_853118630_8" style=3D"display:block; padding:0.5em 0 .5em">
7</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" for=3D"group_853118630_9" style=3D"display:block; padding:0.5em 0 .5em">
8</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" for=3D"group_853118630_10" style=3D"display:block; padding:0.5em 0 .5em">
9</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss-scalenumber" for=3D"group_853118630_11" style=3D"display:block; padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr role=3D"radiogroup" aria-label=3D"Escala Dolor EVA M=EDnimo  Selecciona un valor en el intervalo de 0 a 10 ." style=3D"">
<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 aria-hidden=3D"true" class=3D"aria-todo" style=3D"">
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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"">
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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">
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<input type=3D"radio" name==3D"entry.853118630" disabled=3D"" value=3D"1" id=3D"group_853118630_2" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"1" style=3D"">
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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"">
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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 type=3D"radio" name==3D"entry.853118630" disabled=3D"" value=3D"3" id=3D"group_853118630_4" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"3" 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 type=3D"radio" name==3D"entry.853118630" disabled=3D"" value=3D"4" id=3D"group_853118630_5" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"4" style=3D"">
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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 type=3D"radio" name==3D"entry.853118630" disabled=3D"" value=3D"5" id=3D"group_853118630_6" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"5" 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 type=3D"radio" name==3D"entry.853118630" disabled=3D"" value=3D"6" id=3D"group_853118630_7" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"6" 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 type=3D"radio" name==3D"entry.853118630" disabled=3D"" value=3D"7" id=3D"group_853118630_8" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"7" 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 type=3D"radio" name==3D"entry.853118630" disabled=3D"" value=3D"8" id=3D"group_853118630_9" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"8" 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 type=3D"radio" name==3D"entry.853118630" disabled=3D"" value=3D"9" id=3D"group_853118630_10" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"9" 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 type=3D"radio" name==3D"entry.853118630" disabled=3D"" value=3D"10" id=3D"group_853118630_11" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"10" style=3D"">
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<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-paragraph-text" style=3D"margin:12px 0">
<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" for=3D"entry_2140974612" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Anamnesis/Evoluci=F3n <label for=3D"itemView.getDomIdToLabel()" aria-label==3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
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</div>
</label>
<div class=3D"ss-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%">
REFIERE QUE HA PERSISTIDO CON NAUSEAS Y REFLUJO EN OCASIONES QUE ALIVIA SIN NECESIDAD DE USO DE ANTIEM=C9TICOS, PRACTICAMENTE SIN DOLOR POR LO QUE TOMA EL PARACETAMOL 1 CADA 12 HORAS COMO SE LE DEJO EN ULTIMO CONTROL. SE SIENTE MAS CANSADA QUE ANTES DE FORMA GENERAL, APETITO UN POCO DISMINUIDO YA QUE SIENTE SENSACION DE PLENITUD GASTRICA TRAS ALIMENTARSE, POR LO QUE LA NUTRICIONISTA EN CONTROL REALIZO AJUSTE DE PAUTA ALIMENTICIA NIEGA SINTOMAS RESPIRATORIOS. CON MEJOR ESTAGO GENERAL, AFEBRIL NECESIDADES FISIOLOGICAS CONSERVADAS. ESTADO DE ANIMO EN OCASIONES BIEN Y OTRAS REGULAR. FUE EVALUADA POR KINESIOLOGA QUIEN LA VOLVERA A VISITAR EL DIA LUNES. SE COLOCO TODAS LAS DOSIS DE NEUROBIONTA LAS CUALES FUERON BIEN TOLERADAS.</div>
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<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" for=3D"entry_824006088" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Examen F=EDsico <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
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SNC: VIGIL ORIENTADA EN TIEMPO ESPACIO Y PERSONA, SIN SIGNOS DE FOCALIZACI==D3N NEUROL=D3GICA. CINCINNATI NEGATIVO. PUPILAS ISOC=D3RICAS Y NORMO REACTIVAS. MUCOSAS: LIGERAMENTE HIPOCOLOREADAS Y H=DAMEDAS. PIEL: LIGERA PALIDEZ CUTANEA. ACV: RR2TSS, LLENE CAPILAR MENOR A 2 SEG. TA: 115/88 MMHG FC: 90 POR MIN. AR: MP PRESENTE LOGERAMNTE DISMINUIDO EN BASE A PREDOMINIO DERECHO, SIN RUIDOS AGREGADOS, NO USO DE MUSCULATURA ACCESORIA NI CIANOSIS. SAT: 96%. OROFARINGE: COLORACI=D3N NORMAL SIN EXUDADO, SIN OTRAS ALTERACIONES EVIDENTES. REGI=D3N CERVICAL: NO ADENOPAT=CDAS. ABDOMEN: RHA NORMALES LIGERAMENTE AUMENTADOS, SIN DOLOR A LA PALPACION, EMPASTAMIENTO EN EN MESOGRASTRIO Y FLANCO DERECHO. EVA: 0 EEII: NO EDEMA</div>
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<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
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<label class=3D"ss-q-item-label" for=3D"entry_1690694733" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Diagn=F3stico <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
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CANCER GASTRICO</div>
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<div dir=3D"auto" class=3D"ss-item ss-item-required ss-paragraph-text" style=3D"margin:12px 0">
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<label class=3D"ss-q-item-label" for=3D"entry_1255665248" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
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</label>
<div class=3D"ss-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%">
ADMINISTRARSE VACUNA DE INFLUENZA AUTORIZADA POR ONCOLOGO PSICOEDUCACI=D3N A PACIENTE Y FAMILIAR. ALIMENTACI=D3N SALUDABLE CON ALTO CONTENIDO EN FIBRAS( MEJORAR TRANSITO INTESTINAL) Y VEGETALES PRIORIZAR CONSUMO DE CARNES BLANCAS, EN BASE A RECOMENDACIONES M=C9DICAS. SI SIGNOS Y S=CDNTOMAS DE ALARMA ACUDIR A URGENCIA CORRESPONDIENTE. CONTINUAR TRATAMIENTO PATOLOGIAS CRONICAS.</div>
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<div dir=3D"auto" class=3D"ss-item  ss-paragraph-text" style=3D"margin:12px 0">
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<label class=3D"ss-q-item-label" for=3D"entry_1648939075" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Medicamentos Indicados </div>
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IDEM CONTROL PREVIO </div>
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<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-date" style=3D"margin:12px 0">
<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" for=3D"entry_2063615873" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Fecha aproximada del Pr=F3ximo Control con usted </div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-date" role=3D"group" aria-label=3D"Fecha aproximada del Pr=F3ximo Control con usted  " style=3D"">
<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.2063615873_day" disabled=3D"" class=3D"ss-day-dropdown" id=3D"entry.2063615873_day" aria-label=3D"D=EDa del mes" style=3D"">
<option value=3D"" style=3D"">
D=EDa</option>
 <option value=3D"1" style=3D"">
1</option>
 <option value=3D"2" style=3D"">
2</option>
<option value=3D"3" style=3D"">
3</option>
 <option value=3D"4" style=3D"">
4</option>
 <option value=3D"5" style=3D"">
5</option>
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6</option>
 <option value=3D"7" style=3D"">
7</option>
<option value=3D"8" style=3D"">
8</option>
 <option value=3D"9" style=3D"">
9</option>
 <option value=3D"10" style=3D"">
10</option>
 <option value=3D"11" style=3D"">
11</option>
 <option value=3D"12" style=3D"">
12</option>
 <option value=3D"13" style=3D"">
13</option>
 <option value=3D"14" style=3D"">
14</option>
<option value=3D"15" style=3D"">
15</option>
 <option value=3D"16" style=3D"">
16</option>
 <option value=3D"17" style=3D"">
17</option>
 <option value=3D"18" style=3D"">
18</option>
 <option value=3D"19" style=3D"">
19</option>
 <option value=3D"20" style=3D"">
20</option>
 <option value=3D"21" style=3D"">
21</option>
<option value=3D"22" style=3D"">
22</option>
 <option value=3D"23" style=3D"">
23</option>
 <option value=3D"24" style=3D"">
24</option>
 <option value=3D"25" style=3D"">
25</option>
 <option value=3D"26" selected=3D"" style=3D"">
26</option>
 <option value=3D"27" style=3D"">
27</option>
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28</option>
 <option value=3D"29" style=3D"">
29</option>
 <option value=3D"30" style=3D"">
30</option>
<option value=3D"31" style=3D"">
31</option>
</select>
 <select name=3D"entry.2063615873_month" disabled=3D"" class=3D"ss-month-dropdown" id=3D"entry.2063615873_month" aria-label=3D"Mes" style=3D"">
<option value=3D"" style=3D"">
Mes</option>
 <option value=3D"1" style=3D"">
enero</option>
 <option value=3D"2" style=3D"">
febrero</option>
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marzo</option>
 <option value=3D"4" style=3D"">
abril</option>
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mayo</option>
 <option value==3D"6" selected=3D"" style=3D"">
junio</option>
 <option value=3D"7" style=3D"">
julio</option>
 <option value==3D"8" style=3D"">
agosto</option>
 <option value=3D"9" style=3D"">
septiembre</option>
 <option value=3D"10" style=3D"">
octubre</option>
 <option value=3D"11" style=3D"">
noviembre</option>
 <option value=3D"12" style=3D"">
diciembre</option>
</select>
 <select name=3D"entry.2063615873_year" disabled=3D"" id=3D"entry.2063615873_year" aria-label=3D"A=F1o" style=3D"">
<option value=3D"" style=3D"">
A=F1o</option>
 <option value=3D"1896" style=3D"">
1896</option>
 <option value=3D"1897" style=3D"">
1897</option>
 <option value=3D"1898" style=3D"">
1898</option>
 <option value=3D"1899" style=3D"">
1899</option>
 <option value=3D"1900" style=3D"">
1900</option>
 <option value=3D"1901" style=3D"">
1901</option>
 <option value=3D"1902" style=3D"">
1902</option>
 <option value=3D"1903" style=3D"">
1903</option>
 <option value=3D"1904" style=3D"">
1904</option>
 <option value=3D"1905" style=3D"">
1905</option>
 <option value=3D"1906" style=3D"">
1906</option>
 <option value=3D"1907" style=3D"">
1907</option>
 <option value=3D"1908" style=3D"">
1908</option>
 <option value=3D"1909" style=3D"">
1909</option>
 <option value=3D"1910" style=3D"">
1910</option>
 <option value=3D"1911" style=3D"">
1911</option>
 <option value=3D"1912" style=3D"">
1912</option>
 <option value=3D"1913" style=3D"">
1913</option>
 <option value=3D"1914" style=3D"">
1914</option>
 <option value=3D"1915" style=3D"">
1915</option>
 <option value=3D"1916" style=3D"">
1916</option>
 <option value=3D"1917" style=3D"">
1917</option>
 <option value=3D"1918" style=3D"">
1918</option>
 <option value=3D"1919" style=3D"">
1919</option>
 <option value=3D"1920" style=3D"">
1920</option>
 <option value=3D"1921" style=3D"">
1921</option>
 <option value=3D"1922" style=3D"">
1922</option>
 <option value=3D"1923" style=3D"">
1923</option>
 <option value=3D"1924" style=3D"">
1924</option>
 <option value=3D"1925" style=3D"">
1925</option>
 <option value=3D"1926" style=3D"">
1926</option>
 <option value=3D"1927" style=3D"">
1927</option>
 <option value=3D"1928" style=3D"">
1928</option>
 <option value=3D"1929" style=3D"">
1929</option>
 <option value=3D"1930" style=3D"">
1930</option>
 <option value=3D"1931" style=3D"">
1931</option>
 <option value=3D"1932" style=3D"">
1932</option>
 <option value=3D"1933" style=3D"">
1933</option>
 <option value=3D"1934" style=3D"">
1934</option>
 <option value=3D"1935" style=3D"">
1935</option>
 <option value=3D"1936" style=3D"">
1936</option>
 <option value=3D"1937" style=3D"">
1937</option>
 <option value=3D"1938" style=3D"">
1938</option>
 <option value=3D"1939" style=3D"">
1939</option>
 <option value=3D"1940" style=3D"">
1940</option>
 <option value=3D"1941" style=3D"">
1941</option>
 <option value=3D"1942" style=3D"">
1942</option>
 <option value=3D"1943" style=3D"">
1943</option>
 <option value=3D"1944" style=3D"">
1944</option>
 <option value=3D"1945" style=3D"">
1945</option>
 <option value=3D"1946" style=3D"">
1946</option>
 <option value=3D"1947" style=3D"">
1947</option>
 <option value=3D"1948" style=3D"">
1948</option>
 <option value=3D"1949" style=3D"">
1949</option>
 <option value=3D"1950" style=3D"">
1950</option>
 <option value=3D"1951" style=3D"">
1951</option>
 <option value=3D"1952" style=3D"">
1952</option>
 <option value=3D"1953" style=3D"">
1953</option>
 <option value=3D"1954" style=3D"">
1954</option>
 <option value=3D"1955" style=3D"">
1955</option>
 <option value=3D"1956" style=3D"">
1956</option>
 <option value=3D"1957" style=3D"">
1957</option>
 <option value=3D"1958" style=3D"">
1958</option>
 <option value=3D"1959" style=3D"">
1959</option>
 <option value=3D"1960" style=3D"">
1960</option>
 <option value=3D"1961" style=3D"">
1961</option>
 <option value=3D"1962" style=3D"">
1962</option>
 <option value=3D"1963" style=3D"">
1963</option>
 <option value=3D"1964" style=3D"">
1964</option>
 <option value=3D"1965" style=3D"">
1965</option>
 <option value=3D"1966" style=3D"">
1966</option>
 <option value=3D"1967" style=3D"">
1967</option>
 <option value=3D"1968" style=3D"">
1968</option>
 <option value=3D"1969" style=3D"">
1969</option>
 <option value=3D"1970" style=3D"">
1970</option>
 <option value=3D"1971" style=3D"">
1971</option>
 <option value=3D"1972" style=3D"">
1972</option>
 <option value=3D"1973" style=3D"">
1973</option>
 <option value=3D"1974" style=3D"">
1974</option>
 <option value=3D"1975" style=3D"">
1975</option>
 <option value=3D"1976" style=3D"">
1976</option>
 <option value=3D"1977" style=3D"">
1977</option>
 <option value=3D"1978" style=3D"">
1978</option>
 <option value=3D"1979" style=3D"">
1979</option>
 <option value=3D"1980" style=3D"">
1980</option>
 <option value=3D"1981" style=3D"">
1981</option>
 <option value=3D"1982" style=3D"">
1982</option>
 <option value=3D"1983" style=3D"">
1983</option>
 <option value=3D"1984" style=3D"">
1984</option>
 <option value=3D"1985" style=3D"">
1985</option>
 <option value=3D"1986" style=3D"">
1986</option>
 <option value=3D"1987" style=3D"">
1987</option>
 <option value=3D"1988" style=3D"">
1988</option>
 <option value=3D"1989" style=3D"">
1989</option>
 <option value=3D"1990" style=3D"">
1990</option>
 <option value=3D"1991" style=3D"">
1991</option>
 <option value=3D"1992" style=3D"">
1992</option>
 <option value=3D"1993" style=3D"">
1993</option>
 <option value=3D"1994" style=3D"">
1994</option>
 <option value=3D"1995" style=3D"">
1995</option>
 <option value=3D"1996" style=3D"">
1996</option>
 <option value=3D"1997" style=3D"">
1997</option>
 <option value=3D"1998" style=3D"">
1998</option>
 <option value=3D"1999" style=3D"">
1999</option>
 <option value=3D"2000" style=3D"">
2000</option>
 <option value=3D"2001" style=3D"">
2001</option>
 <option value=3D"2002" style=3D"">
2002</option>
 <option value=3D"2003" style=3D"">
2003</option>
 <option value=3D"2004" style=3D"">
2004</option>
 <option value=3D"2005" style=3D"">
2005</option>
 <option value=3D"2006" style=3D"">
2006</option>
 <option value=3D"2007" style=3D"">
2007</option>
 <option value=3D"2008" style=3D"">
2008</option>
 <option value=3D"2009" style=3D"">
2009</option>
 <option value=3D"2010" style=3D"">
2010</option>
 <option value=3D"2011" style=3D"">
2011</option>
 <option value=3D"2012" style=3D"">
2012</option>
 <option value=3D"2013" style=3D"">
2013</option>
 <option value=3D"2014" style=3D"">
2014</option>
 <option value=3D"2015" style=3D"">
2015</option>
 <option value=3D"2016" style=3D"">
2016</option>
 <option value=3D"2017" style=3D"">
2017</option>
 <option value=3D"2018" style=3D"">
2018</option>
 <option value=3D"2019" selected=3D"" style=3D"">
2019</option>
 <option value=3D"2020" style=3D"">
2020</option>
 <option value=3D"2021" style=3D"">
2021</option>
 <option value=3D"2022" style=3D"">
2022</option>
 <option value=3D"2023" style=3D"">
2023</option>
 <option value=3D"2024" style=3D"">
2024</option>
 <option value=3D"2025" style=3D"">
2025</option>
 <option value=3D"2026" style=3D"">
2026</option>
 <option value=3D"2027" style=3D"">
2027</option>
 <option value=3D"2028" style=3D"">
2028</option>
 <option value=3D"2029" style=3D"">
2029</option>
 <option value=3D"2030" style=3D"">
2030</option>
 <option value=3D"2031" style=3D"">
2031</option>
 <option value=3D"2032" style=3D"">
2032</option>
 <option value=3D"2033" style=3D"">
2033</option>
 <option value=3D"2034" style=3D"">
2034</option>
 <option value=3D"2035" style=3D"">
2035</option>
 <option value=3D"2036" style=3D"">
2036</option>
 <option value=3D"2037" style=3D"">
2037</option>
 <option value=3D"2038" style=3D"">
2038</option>
 <option value=3D"2039" style=3D"">
2039</option>
 <option value=3D"2040" style=3D"">
2040</option>
 <option value=3D"2041" style=3D"">
2041</option>
 <option value=3D"2042" style=3D"">
2042</option>
 <option value=3D"2043" style=3D"">
2043</option>
 <option value=3D"2044" style=3D"">
2044</option>
 <option value=3D"2045" style=3D"">
2045</option>
 <option value=3D"2046" style=3D"">
2046</option>
 <option value=3D"2047" style=3D"">
2047</option>
 <option value=3D"2048" style=3D"">
2048</option>
 <option value=3D"2049" style=3D"">
2049</option>
 <option value=3D"2050" style=3D"">
2050</option>
 <option value=3D"2051" style=3D"">
2051</option>
 <option value=3D"2052" style=3D"">
2052</option>
 <option value=3D"2053" style=3D"">
2053</option>
 <option value=3D"2054" style=3D"">
2054</option>
 <option value=3D"2055" style=3D"">
2055</option>
 <option value=3D"2056" style=3D"">
2056</option>
 <option value=3D"2057" style=3D"">
2057</option>
 <option value=3D"2058" style=3D"">
2058</option>
 <option value=3D"2059" style=3D"">
2059</option>
 <option value=3D"2060" style=3D"">
2060</option>
 <option value=3D"2061" style=3D"">
2061</option>
 <option value=3D"2062" style=3D"">
2062</option>
 <option value=3D"2063" style=3D"">
2063</option>
 <option value=3D"2064" style=3D"">
2064</option>
 <option value=3D"2065" style=3D"">
2065</option>
 <option value=3D"2066" style=3D"">
2066</option>
 <option value=3D"2067" style=3D"">
2067</option>
 <option value=3D"2068" style=3D"">
2068</option>
 <option value=3D"2069" style=3D"">
2069</option>
</select>
 </div>
</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-text" style=3D"margin:12px 0">
<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" for=3D"entry_74766472" style=3D"">
<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" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-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"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-checkbox" style=3D"margin:12px 0">
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<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" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
S=F3lo llene esta secci=F3n si es m=E9dico y solicita la visita de otro prestador del equipo</div>
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<ul class=3D"ss-choices" role=3D"group" 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 " style=3D"list-style:none; padding:0; margin:.5em 0 0">
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<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled=3D"" value=3D"ENFERMERA" id=3D"group_503039759_1" role=3D"checkbox" class=3D"ss-q-checkbox" style=3D"">
</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 type=3D"checkbox" name=3D"entry.503039759" disabled=3D"" value=3D"TENS" id=3D"group_503039759_2" role=3D"checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
TENS</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 type=3D"checkbox" name=3D"entry.503039759" disabled=3D"" value=3D"NUTRICIONISTA" id=3D"group_503039759_3" role=3D"checkbox" class=3D"ss-q-checkbox" style=3D"">
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<span class=3D"ss-choice-label" style=3D"">
NUTRICIONISTA</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 type=3D"checkbox" name=3D"entry.503039759" disabled=3D"" value=3D"KINESIOLOGO" id=3D"group_503039759_4" role=3D"checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
KINESIOLOGO</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 type=3D"checkbox" name=3D"entry.503039759" disabled=3D"" value=3D"PSICOLOGO" id=3D"group_503039759_5" role=3D"checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
PSICOLOGO</span>
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<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style==3D"margin:12px 0; max-width:100%">
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<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 class=3D"ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A">
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<tr height=3D"24px">
</tr>
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</div>
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%" role=3D"presentation" style=3D"max-width:672px; min-width:154px">
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<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242; font-size:13px">
Crea tu propio formulario de Google</a>
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