<div dir=3D"ltr">
<br>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class==3D"gmail_attr">
---------- Forwarded message ---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Google Forms</strong>
 <span dir=3D"auto">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: vie., 28 jun. 2019 a las 15:58<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:k7albarran@gmail.com">
k7albarran@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Google Forms" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Thanks for filling out <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target=3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height==3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Here&#39;s what we got from you:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_-892647602130501614ss-form-container">
<div class=3D"m_-892647602130501614ss-form-heading">
<h1 class=3D"m_-892647602130501614ss-form-title" dir==3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_-892647602130501614ss-form-desc m_-892647602130501614ss-no-ignore-whitespace" style=3D"font:inherit;width:99%;margin:0 0 1em;white-space:pre-wrap;word-wrap:break-word">
Este es el sistema de registro de atenciones domiciliarias de Oncovida.   Debe ser llenado por el prestador individual, y debe realizarse un registro por cada visita domiciliaria.   Si usted no es prestador de Oncovida por favor no llene este formulario.   A continuaci=C3=B3n indique su correo electr=C3=B3nico.</div>
</div>
<div class=3D"m_-892647602130501614ss-form">
<form method=3D"GET" id=3D"m_-892647602130501614ss-form" target=3D"_blank">
<br>
<div class=3D"m_-892647602130501614ss-form-question m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-item-required m_-892647602130501614ss-text" style=3D"margin:12px 0">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-892647602130501614ss-q-item-label" for=3D"m_-892647602130501614emailAddress">
<div class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Email address<label for=3D"m_-892647602130501614emailAddress">
</label>
<span class=3D"m_-892647602130501614ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_-892647602130501614ss-q-text m_-892647602130501614ss-printable-text-line" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
<a href=3D"mailto:k7albarran@gmail.com" target=3D"_blank">
k7albarran@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_-892647602130501614ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-892647602130501614ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_-892647602130501614ss-page-description m_-892647602130501614ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
Aqu=C3=AD debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614ss-form-question m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-item-required m_-892647602130501614ss-text" style=3D"margin:12px 0">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-892647602130501614ss-q-item-label" for=3D"m_-892647602130501614entry_579114469">
<div class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_-892647602130501614itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-892647602130501614ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-892647602130501614ss-q-help m_-892647602130501614ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-892647602130501614ss-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%">
Kattia Albarran</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614ss-form-question m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-item-required m_-892647602130501614ss-text" style=3D"margin:12px 0">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-892647602130501614ss-q-item-label" for=3D"m_-892647602130501614entry_1276273985">
<div class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_-892647602130501614itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-892647602130501614ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-892647602130501614ss-q-help m_-892647602130501614ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_-892647602130501614ss-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%">
16152053-5</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614ss-form-question m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-item-required m_-892647602130501614ss-select" style=3D"margin:12px 0">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-892647602130501614ss-q-item-label" for=3D"m_-892647602130501614entry_133691676">
<div class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_-892647602130501614itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-892647602130501614ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-892647602130501614ss-q-help m_-892647602130501614ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
Si asisten m=C3=A1s de 1 prestador simult=C3=A1neamente, cada uno debe hacer un registro independiente</div>
</label>
<select name=3D"entry.133691676" disabled id=3D"m_-892647602130501614entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled selected>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_-892647602130501614ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-892647602130501614ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_-892647602130501614ss-page-description m_-892647602130501614ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-892647602130501614ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_-892647602130501614ss-section-description m_-892647602130501614ss-no-ignore-whitespace" style=3D"margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614ss-form-question m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-item-required m_-892647602130501614ss-text" style=3D"margin:12px 0">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-892647602130501614ss-q-item-label" for=3D"m_-892647602130501614entry_823811303">
<div class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_-892647602130501614itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-892647602130501614ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-892647602130501614ss-q-help m_-892647602130501614ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_-892647602130501614ss-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%">
11680772-6</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614ss-form-question m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-item-required m_-892647602130501614ss-text" style=3D"margin:12px 0">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-892647602130501614ss-q-item-label" for=3D"m_-892647602130501614entry_1959365839">
<div class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente<label for=3D"m_-892647602130501614itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-892647602130501614ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-892647602130501614ss-q-help m_-892647602130501614ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-892647602130501614ss-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%">
Corina Molina</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614ss-form-question m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-item-required m_-892647602130501614ss-select" style=3D"margin:12px 0">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-892647602130501614ss-q-item-label" for=3D"m_-892647602130501614entry_545002227">
<div class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_-892647602130501614itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-892647602130501614ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-892647602130501614ss-q-help m_-892647602130501614ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.545002227" disabled id=3D"m_-892647602130501614entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled>
COLMENA</option>
 <option value=3D"CONSALUD" disabled>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value==3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled selected>
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled>
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614ss-form-question m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-item-required m_-892647602130501614ss-text" style=3D"margin:12px 0">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-892647602130501614ss-q-item-label" for=3D"m_-892647602130501614entry_1900161356">
<div class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_-892647602130501614itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-892647602130501614ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-892647602130501614ss-q-help m_-892647602130501614ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-892647602130501614ss-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%">
Talcahuano</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614ss-form-question m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-item-required m_-892647602130501614ss-text" style=3D"margin:12px 0">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-892647602130501614ss-q-item-label" for=3D"m_-892647602130501614entry_1298871758">
<div class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_-892647602130501614itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-892647602130501614ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-892647602130501614ss-q-help m_-892647602130501614ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-892647602130501614ss-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%">
Hualp=C3=A9n</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_-892647602130501614ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-892647602130501614ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_-892647602130501614ss-page-description m_-892647602130501614ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos de la atenci==C3=B3n domiciliaria</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614ss-form-question m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-item-required m_-892647602130501614ss-radio" style=3D"margin:12px 0">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-892647602130501614ss-q-item-label" for=3D"m_-892647602130501614entry_2073233714">
<div class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_-892647602130501614itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-892647602130501614ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-892647602130501614ss-q-help m_-892647602130501614ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_-892647602130501614ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-892647602130501614ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-892647602130501614ss-choice-item-control m_-892647602130501614goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_-892647602130501614group_1222378237_1" class=3D"m_-892647602130501614ss-q-radio">
</span>
<span class=3D"m_-892647602130501614ss-choice-label">
Domicilio</span>
</label>
</li>
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<label>
<span class=3D"m_-892647602130501614ss-choice-item-control m_-892647602130501614goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_-892647602130501614group_1222378237_2" class=3D"m_-892647602130501614ss-q-radio">
</span>
<span class=3D"m_-892647602130501614ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614ss-form-question m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-item-required m_-892647602130501614ss-date" style=3D"margin:12px 0">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-892647602130501614ss-q-item-label" for=3D"m_-892647602130501614entry_1705849412">
<div class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha de la Atenci=C3=B3n<label for=3D"m_-892647602130501614itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-892647602130501614ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-892647602130501614ss-q-help m_-892647602130501614ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-892647602130501614ss-q-date">
<div class=3D"m_-892647602130501614ss-datetime-box m_-892647602130501614goog-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">
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<option value=3D"">
Month</option>
<option value=3D"1">
January</option>
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February</option>
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March</option>
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April</option>
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May</option>
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June</option>
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July</option>
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August</option>
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September</option>
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October</option>
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November</option>
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December</option>
</select>
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<option value=3D"">
Day</option>
<option value=3D"1">
1</option>
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2</option>
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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>
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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>
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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>
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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>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_-892647602130501614entry.1705849412_year">
<option value=3D"">
Year</option>
<option value=3D"1896">
1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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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>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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1979</option>
 <option value==3D"1980">
1980</option>
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1981</option>
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1982</option>
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1983</option>
 <option value==3D"1984">
1984</option>
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1985</option>
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1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
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1989</option>
 <option value==3D"1990">
1990</option>
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1991</option>
 <option value==3D"1992">
1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
 <option value==3D"1998">
1998</option>
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1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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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>
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2023</option>
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2024</option>
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2025</option>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
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2032</option>
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2033</option>
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2034</option>
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2035</option>
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2036</option>
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2037</option>
 <option value==3D"2038">
2038</option>
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2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
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2043</option>
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2044</option>
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2045</option>
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2046</option>
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2047</option>
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2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
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2055</option>
 <option value==3D"2056">
2056</option>
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2057</option>
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2058</option>
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2059</option>
 <option value==3D"2060">
2060</option>
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2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614ss-form-question m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-item-required m_-892647602130501614ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-892647602130501614ss-q-item-label" for=3D"m_-892647602130501614entry_206244955">
<div class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Hora de la Atenci=C3=B3n<label for=3D"m_-892647602130501614itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-892647602130501614ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-892647602130501614ss-q-help m_-892647602130501614ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-892647602130501614ss-q-time">
<div class=3D"m_-892647602130501614ss-datetime-box m_-892647602130501614goog-inline-block" dir=3D"ltr" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
<select name=3D"entry.206244955_hour" disabled id=3D"m_-892647602130501614entry.206244955_hour">
<option value=3D"">
Hr</option>
<option value=3D"01">
01</option>
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02</option>
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03</option>
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04</option>
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05</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>
 <option value=3D"10">
10</option>
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11</option>
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12</option>
</select>
:<select name=3D"entry.206244955_minute" disabled id=3D"m_-892647602130501614entry.206244955_minute">
<option value=3D"">
Min</option>
<option value=3D"00">
00</option>
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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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05</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>
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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>
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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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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>
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37</option>
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38</option>
 <option value=3D"39">
39</option>
 <option value=3D"40">
40</option>
 <option value=3D"41">
41</option>
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42</option>
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43</option>
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44</option>
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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>
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52</option>
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53</option>
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54</option>
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55</option>
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56</option>
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57</option>
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58</option>
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59</option>
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AM</option>
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PM</option>
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</div>
</div>
</div>
</div>
</div>
</div>
<br>
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<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-item-required m_-892647602130501614ss-select" style=3D"margin:12px 0">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-892647602130501614ss-q-item-label" for=3D"m_-892647602130501614entry_1747608258">
<div class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_-892647602130501614itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-892647602130501614ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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<div class=3D"m_-892647602130501614ss-q-help m_-892647602130501614ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
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<select name=3D"entry.1747608258" disabled id=3D"m_-892647602130501614entry_1747608258">
<option value=3D"">
</option>
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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>
</select>
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</div>
</div>
<br>
 <div class=3D"m_-892647602130501614ss-form-question m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-892647602130501614ss-q-item-label" for=3D"m_-892647602130501614entry_1716090865">
<div class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_-892647602130501614ss-q-help m_-892647602130501614ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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<tbody>
<tr>
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</td>
<td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
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<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1421689035_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
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<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
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<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
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<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-892647602130501614ss-scalerow m_-892647602130501614ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_-892647602130501614aria-todo">
</div>
</td>
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</div>
</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value==3D"1" id=3D"m_-892647602130501614group_1421689035_2" class=3D"m_-892647602130501614ss-q-radio">
</div>
</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"2" id=3D"m_-892647602130501614group_1421689035_3" class=3D"m_-892647602130501614ss-q-radio">
</div>
</td>
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<div class=3D"m_-892647602130501614ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3" id=3D"m_-892647602130501614group_1421689035_4" class=3D"m_-892647602130501614ss-q-radio">
</div>
</td>
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<div class=3D"m_-892647602130501614ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_-892647602130501614group_1421689035_5" class=3D"m_-892647602130501614ss-q-radio">
</div>
</td>
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<div class=3D"m_-892647602130501614ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_-892647602130501614group_1421689035_6" class=3D"m_-892647602130501614ss-q-radio">
</div>
</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_-892647602130501614group_1421689035_7" class=3D"m_-892647602130501614ss-q-radio">
</div>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"7" id=3D"m_-892647602130501614group_1421689035_8" class=3D"m_-892647602130501614ss-q-radio">
</div>
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</div>
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<input type=3D"radio" name==3D"entry.1421689035" disabled value=3D"10" id=3D"m_-892647602130501614group_1421689035_11" class=3D"m_-892647602130501614ss-q-radio">
</div>
</td>
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</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_-892647602130501614ss-form-question m_-892647602130501614errorbox-good">
<div dir=3D"auto" class=3D"m_-892647602130501614ss-item m_-892647602130501614ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-892647602130501614ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-892647602130501614ss-q-item-label" for=3D"m_-892647602130501614entry_2064050596">
<div class=3D"m_-892647602130501614ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=A1ximo</div>
<div class=3D"m_-892647602130501614ss-q-help m_-892647602130501614ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_-892647602130501614entry_1244707512">
<tbody>
<tr>
<td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-892647602130501614ss-scalenumber" for=3D"m_-892647602130501614group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-892647602130501614ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-892647602130501614ss-scalerow m_-892647602130501614ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_-892647602130501614aria-todo">
</div>
</td>
<td class=3D"m_-892647602130501614ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_-892647602130501614ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled checked value=3D"0" id=3D"m_-892647602130501614group_1244707512_1" class=3D"m_-892647602130501614ss-q-radio">
</div>
</td>
 <td class=3D"m_-892647602130501614ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_-892647602130501614ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value==3D"1" id=3D"m_-892647602130501614group_1244707512_2" class=3D"m_-892647602130501614ss-q-radio">
</div>
</td>
 <td class=3D"m_-892647602130501614ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_-892647602130501614ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"2" id=3D"m_-892647602130501614group_1244707512_3" class=3D"m_-892647602130501614ss-q-radio">
</div>
</td>
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<div class=3D"m_-892647602130501614ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"3" id=3D"m_-892647602130501614group_1244707512_4" class=3D"m_-892647602130501614ss-q-radio">
</div>
</td>
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<div class=3D"m_-892647602130501614ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"4" id=3D"m_-892647602130501614group_1244707512_5" class=3D"m_-892647602130501614ss-q-radio">
</div>
</td>
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<div class=3D"m_-892647602130501614ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"5" id=3D"m_-892647602130501614group_1244707512_6" class=3D"m_-892647602130501614ss-q-radio">
</div>
</td>
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Paciente relata antecedentes de trastorno depresivo-ansioso en tratamiento desde hace m=C3=A1s menos 1 a=C3=B1o con Escitalopram 10mg por d=C3=ADa y clonazepam 0,5mg 12 por noche y =C2=BD SOS, tras ruptura amorosa, es usuaria de GES de depresi=C3=B3n en su Isapre. En marzo del 2019, le toman ex=C3=A1menes que destacan TSH: 7, 46. Con Anticuerpos Antitiroglobulina  y antimicrosomales en t=C3=ADtulo alto, por lo que se diagnostica con Hipotiroidismo autoinmune (Tiroiditis de Hashimoto). Comienza tratamiento con Eutirox 25mg los d=C3=ADas lunes, martes y mi=C3=A9rcoles y 50 mg los d=C3=ADas jueves, viernes s=C3=A1bado y domingo. Adem=C3=A1s para confirmar diagn=C3=B3stico le indican Ecodoppler tiroideo que destaca: Bocio difuso heterog=C3=A9neo, dos lesiones nodulares, una peque==C3=B1a a derecha y otra de mayor tama=C3=B1o a izquierda con caracter=C3==ADsticas neopl=C3=A1sicas. Lesi=C3=B3n nodular heterog=C3=A9nea en el contorno medial del l=C3=B3bulo derecho y lesiones nodulares hipoecog=C3=A9nicas m=C3=BAltiples, con aspecto de quistes coloideos tipo 2. Adenopat=C3=ADas derechas altas nivel II, con aspecto de sustituci=C3=B3n de su par=C3=A9nquima. Se clasifica como TIRADS 4B y se sugiere estudio histol=C3=B3gico. Se le realiza punci=C3=B3n con  aguja fina que revela tiroiditis de Hashimoto Betsheda II, y lesi=C3=B3n folicular indeterminada con metaplasia de Hurthle, Betsheda III. Se Diagnostica por lo tanto como c=C3=A1ncer de tiroides y se deriva para ingreso a GES de cuidados paliativos. Aun no presenta etapificaci=C3=B3n ni tampoco le han realizado tac toracoabdominal para evaluar otras lesiones. Tiene pendiente hora a cirug=C3=ADa de Cabeza y Cuello para el 2.07.2019 para determinar criterios de resecabilidad y tratamiento.  Actualmente no refiere dolor, ni molestias  s=C3=B3lo con tos escasamente productiva mucosa, sin sensaci=C3=B3n febril, leve coriza desde hace mas menos 2 semanas. Deposiciones dif=C3=ADciles y cada mas menos 2 d=C3=ADas, micci=C3=B3n normal, se alimenta regularmente, con mala calidad de comidas. No ha presentado baja de peso importante ni signos de s=C3=ADndrome constitucional. </div>
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Examen F=C3=ADsico<label for=3D"m_-892647602130501614itemView.getDomIdToLabel()">
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Pa: 110/80 mmhg=20Sat: 97% ambientalFc: 76 por min=20T: 36,5 =C2=B0cFr: 18 por min=20Conciente, l=C3=BAcida, orientada temporo-espacialmente, con conciencia de enfermedad, levemente pueril y de personalidad dependiente-ansiosa.  Piel y tegumentos sin alteraciones evidentes. Eutr=C3=B3fica, sin facie caracter==C3=ADstica.  Buena hidrataci=C3=B3n. Pulsos perif=C3=A9ricos + sim=C3=A9tricos bilaterales.=20Cabeza y Cuello: Tiroides palpable, grado II. De superficie irregular en ambos l=C3=B3bulos, de consistencia blanda. Se palpan adenopat=C3=ADas en cadena ganglionar cervical anterior en racimos, levemente sensibles, no adheridos a planos profundos de consistencia blanda. Se palpa adenopat=C3=ADa cervical en cadena ganglionar anterior derecha de mas menos 2 cm de consistencia p=C3=A9trea adherido a planos profundos, levemente sensible. Sin cambios en piel de cuello. Yugulares planas a 45 =C2=B0. =20T=C3=B3rax: Expansi=C3=B3n conservada, no se observan alteraciones en piel ni cicatrices.=20Card=C3=ADaco: RR2TSSPulmonar: Mp + con estertores bibasales aislados. Cr=C3=A9pitos =E2=80=93 sibilancias aisladas bilaterales. Sonoridad conservada. No se palpan adenopat=C3=ADas supra ni infraclaviculares ni axilares o masas mamarias.=20Abdomen: Blando, depresible, sensible difuso, RHA+ levemente aumentados. Sin signos de irritaci=C3=B3n peritoneal, no se palpan masas ni megalias. No se palpan adenopat=C3=ADas inguinales.=20EEII: Edema: -/- no se evidencia disminuci=C3=B3n en rango articular ni dolor a la movilizaci=C3=B3n en =C3=A9ste momento. Pulsos + bilaterales sin signos de tvp.=20</div>
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C=C3=A1ncer de tiroides</div>
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Plan de Tratamiento e Indicaciones<label for=3D"m_-892647602130501614itemView.getDomIdToLabel()">
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Evaluaci=C3=B3n por m=C3=A9dico, enfermer=C3=ADa, nutricionista y psic=C3=B3logo 1 vez por semanaR=C3=A9gimen de preferencia alcalino hiperproteico y aumento en consumo de fibra vegetal- aumento de ingesta h=C3=ADdrica a 2 lts al d=C3=ADa.=20Pendiente evaluaci=C3=B3n por cirujano de cabeza y cuello el 2.7.2019</div>
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Medicamentos Indicados</div>
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T4 Bag=C3=B3 25mg lu-ma-mi/ 50mg ju-vi-sa-doClonazepam 0,5 mg =C2=BD por noche y =C2=BD SOSEscitalopram 10mg 1 por d=C3=ADa en la ma=C3=B1anaControl servicio de urgencias en caso de signos de alarma.=20</div>
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Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
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Month</option>
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January</option>
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5</option>
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6</option>
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7</option>
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8</option>
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10</option>
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11</option>
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25</option>
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1899</option>
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1900</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1910</option>
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1911</option>
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1914</option>
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1918</option>
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1919</option>
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1920</option>
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1932</option>
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1939</option>
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1940</option>
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1944</option>
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1951</option>
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1952</option>
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1953</option>
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1956</option>
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1957</option>
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1960</option>
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1963</option>
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1964</option>
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1966</option>
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1967</option>
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1968</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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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>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1997</option>
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1998</option>
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2000</option>
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2001</option>
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2002</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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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>
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2023</option>
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2024</option>
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2025</option>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
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2032</option>
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2033</option>
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2034</option>
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2035</option>
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2036</option>
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2037</option>
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2038</option>
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2039</option>
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2040</option>
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2041</option>
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2042</option>
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2043</option>
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2044</option>
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2045</option>
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2046</option>
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2047</option>
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2048</option>
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2049</option>
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2050</option>
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2051</option>
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2052</option>
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2053</option>
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2054</option>
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2055</option>
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2056</option>
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2057</option>
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2058</option>
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2059</option>
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2060</option>
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2061</option>
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2062</option>
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2063</option>
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2064</option>
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2065</option>
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2066</option>
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2067</option>
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2068</option>
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2069</option>
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Tratamiento Realizado (si corresponde)</div>
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Derivaci=C3=B3n a otro Prestador Domiciliario</div>
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S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
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TENS</span>
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NUTRICIONISTA</span>
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