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<b>
De:</b>
 Formularios de Google &lt;forms-receipts-noreply@google.com&gt;<br>
<b>
Enviado:</b>
 viernes, 12 de julio de 2019 15:17:20<br>
<b>
Para:</b>
 ailyn_basaez@hotmail.com<br>
<b>
Asunto:</b>
 Registro de Atenci=F3n Domiciliaria Oncovida</font>
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&nbsp;</div>
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<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" width=3D"100%" role=3D"presentation" style=3D"background-color:rgb(38,4,154)">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<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>
</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" 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"x_ss-form-container" style=3D"">
<div class=3D"x_ss-form-heading" style=3D"">
<h1 class=3D"x_ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=F3n Domiciliaria Oncovida</h1>
<div class=3D"x_ss-form-desc x_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"x_ss-form" style=3D"">
<form action=3D"" method=3D"GET" id=3D"x_ss-form" style=3D"">
<br>
<div class=3D"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-item-required x_ss-text" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"emailAddress" style=3D"">
<div class=3D"x_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"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"x_ss-q-text x_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%">
ailyn_basaez@hotmail.com</div>
</div>
</div>
</div>
<div class=3D"x_errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-embeddable-object-container" style=3D"margin:12px 0; max-width:100%">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"x_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"x_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"x_errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-page-break" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"x_ss-page-title" style=3D"padding:0.4em; background-color:#eee">
Identificaci=F3n del Prestador</h2>
<div class=3D"x_ss-page-description x_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"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-item-required x_ss-text" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_579114469" style=3D"">
<div class=3D"x_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"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
*</span>
</div>
<div class=3D"x_ss-q-help x_ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"x_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%">
Ailyn Bas=E1ez </div>
</div>
</div>
</div>
<br>
<div class=3D"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-item-required x_ss-text" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_1276273985" style=3D"">
<div class=3D"x_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"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
*</span>
</div>
<div class=3D"x_ss-q-help x_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"x_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%">
14593649-7</div>
</div>
</div>
</div>
<br>
<div class=3D"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-item-required x_ss-select" style==3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_133691676" style=3D"">
<div class=3D"x_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"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
*</span>
</div>
<div class=3D"x_ss-q-help x_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"x_entry.133691676" disabled=3D"" id=3D"x_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"" 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"" selected=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"x_errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-embeddable-object-container" style=3D"margin:12px 0; max-width:100%">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"x_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"x_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"x_errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-page-break" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"x_ss-page-title" style=3D"padding:0.4em; background-color:#eee">
Identificaci=F3n del Paciente</h2>
<div class=3D"x_ss-page-description x_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"x_errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-section-header" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"x_ss-section-title" style=3D"background-color:#eee; padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"x_ss-section-description x_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"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-item-required x_ss-text" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_823811303" style=3D"">
<div class=3D"x_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"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
*</span>
</div>
<div class=3D"x_ss-q-help x_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"x_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%">
10553175-3</div>
</div>
</div>
</div>
<br>
<div class=3D"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-item-required x_ss-text" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_1959365839" style=3D"">
<div class=3D"x_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"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
*</span>
</div>
<div class=3D"x_ss-q-help x_ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"x_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%">
H=E9ctor Barrera</div>
</div>
</div>
</div>
<br>
<div class=3D"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-item-required x_ss-select" style==3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_545002227" style=3D"">
<div class=3D"x_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"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
*</span>
</div>
<div class=3D"x_ss-q-help x_ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<select name=3D"x_entry.545002227" disabled=3D"" id=3D"x_entry_545002227" aria-label=3D"Previsi=F3n  " style=3D"">
<option value=3D"" style=3D"">
</option>
 <option value=3D"BANMEDICA" disabled=3D"" selected=3D"" style=3D"">
BANMEDICA</option>
<option value=3D"CAPREDENA" disabled=3D"" style=3D"">
CAPREDENA</option>
 <option value=3D"COLMENA" disabled=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"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-item-required x_ss-text" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_1900161356" style=3D"">
<div class=3D"x_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"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
*</span>
</div>
<div class=3D"x_ss-q-help x_ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"x_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%">
Quilpu=E9 </div>
</div>
</div>
</div>
<br>
<div class=3D"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-item-required x_ss-text" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_1298871758" style=3D"">
<div class=3D"x_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"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
*</span>
</div>
<div class=3D"x_ss-q-help x_ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"x_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%">
Quilpu=E9 </div>
</div>
</div>
</div>
<br>
<div class=3D"x_errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-embeddable-object-container" style=3D"margin:12px 0; max-width:100%">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"x_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"x_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"x_errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-page-break" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"x_ss-page-title" style=3D"padding:0.4em; background-color:#eee">
Registro de la Atenci=F3n Domiciliaria</h2>
<div class=3D"x_ss-page-description x_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"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-item-required x_ss-radio" style==3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_2073233714" style=3D"">
<div class=3D"x_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"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
*</span>
</div>
<div class=3D"x_ss-q-help x_ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<ul class=3D"x_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"x_ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"x_ss-choice-item-control x_goog-inline-block" style==3D"display:inline-block">
<input type=3D"radio" name=3D"x_entry.1222378237" disabled=3D"" checked=3D"" value=3D"Domicilio" id=3D"x_group_1222378237_1" role=3D"radio" class=3D"x_ss-q-radio">
</span>
<span class=3D"x_ss-choice-label" style=3D"">
Domicilio</span>
 </label>
</li>
<li class=3D"x_ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"x_ss-choice-item-control x_goog-inline-block" style==3D"display:inline-block">
<input type=3D"radio" name=3D"x_entry.1222378237" disabled=3D"" value=3D"Ambulatorio" id=3D"x_group_1222378237_2" role=3D"radio" class=3D"x_ss-q-radio" aria-label=3D"Ambulatorio">
</span>
<span class=3D"x_ss-choice-label" style=3D"">
Ambulatorio</span>
 </label>
</li>
</ul>
</div>
</div>
</div>
<br>
<div class=3D"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-item-required x_ss-date" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_1705849412" style=3D"">
<div class=3D"x_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"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
*</span>
</div>
<div class=3D"x_ss-q-help x_ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"x_ss-q-date" role=3D"group" aria-label=3D"Fecha de la Atenci==F3n  " style=3D"">
<div class=3D"x_ss-datetime-box x_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"x_entry.1705849412_day" disabled=3D"" class=3D"x_ss-day-dropdown" id=3D"x_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" selected=3D"" 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" 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"x_entry.1705849412_month" disabled=3D"" class=3D"x_ss-month-dropdown" id=3D"x_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" style=3D"">
junio</option>
 <option value=3D"7" selected=3D"" 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"x_entry.1705849412_year" disabled=3D"" id=3D"x_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"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-item-required x_ss-time" style=3D"margin:12px 0; font:inherit">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_206244955" style=3D"">
<div class=3D"x_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"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
*</span>
</div>
<div class=3D"x_ss-q-help x_ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"x_ss-q-time" style=3D"">
<div class=3D"x_ss-datetime-box x_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"x_entry.206244955_hour" disabled=3D"" id=3D"x_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>
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14</option>
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23</option>
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31</option>
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34</option>
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35</option>
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38</option>
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39</option>
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40</option>
<option value=3D"41" style=3D"">
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>
<option value=3D"48" style=3D"">
48</option>
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49</option>
 <option value=3D"50" style=3D"">
50</option>
 <option value=3D"51" style=3D"">
51</option>
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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>
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59</option>
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<div class=3D"x_ss-form-question x_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"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
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Escala Dolor EVA Actual </div>
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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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<input type=3D"radio" name=3D"x_entry.1421689035" disabled=3D"" value=3D"6" id=3D"x_group_1421689035_7" role=3D"radio" class=3D"x_ss-q-radio" aria-label=3D"6">
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</div>
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<br>
<div class=3D"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
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<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
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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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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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<label class=3D"x_ss-scalenumber" for=3D"group_1244707512_10" style=3D"display:block; padding:0.5em 0 .5em">
9</label>
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<label class=3D"x_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"x_ss-scalenumbers" style=3D"text-align:center">
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<div class=3D"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-scale" style=3D"margin:12px 0; overflow-x:auto">
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<label class=3D"x_ss-q-item-label" for=3D"entry_2000523015" style=3D"">
<div class=3D"x_ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Escala Dolor EVA M=EDnimo </div>
<div class=3D"x_ss-q-help x_ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
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<label class=3D"x_ss-scalenumber" for=3D"group_853118630_1" style=3D"display:block; padding:0.5em 0 .5em">
0</label>
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<label class=3D"x_ss-scalenumber" for=3D"group_853118630_2" style=3D"display:block; padding:0.5em 0 .5em">
1</label>
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<label class=3D"x_ss-scalenumber" for=3D"group_853118630_3" style=3D"display:block; padding:0.5em 0 .5em">
2</label>
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3</label>
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<label class=3D"x_ss-scalenumber" for=3D"group_853118630_5" style=3D"display:block; padding:0.5em 0 .5em">
4</label>
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5</label>
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6</label>
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<label class=3D"x_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"x_ss-scalenumbers" style=3D"text-align:center">
<label class=3D"x_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"x_ss-scalenumbers" style=3D"text-align:center">
<label class=3D"x_ss-scalenumber" for=3D"group_853118630_10" style=3D"display:block; padding:0.5em 0 .5em">
9</label>
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<label class=3D"x_ss-scalenumber" for=3D"group_853118630_11" style=3D"display:block; padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"x_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"">
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<div aria-hidden=3D"true" class=3D"x_aria-todo" style=3D"">
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<td class=3D"x_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"x_entry.853118630" disabled=3D"" value=3D"3" id=3D"x_group_853118630_4" role=3D"radio" class=3D"x_ss-q-radio" aria-label=3D"3">
</div>
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<td class=3D"x_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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</table>
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<div class=3D"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
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<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_2140974612" style=3D"">
<div class=3D"x_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"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
*</span>
</div>
<div class=3D"x_ss-q-help x_ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
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</label>
<div class=3D"x_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%">
Paciente de buen =E1nimo, cooperador, presenta congesti=F3n nasal y ruido bronquial debido a cuadro viral en curso.</div>
</div>
</div>
</div>
<br>
<div class=3D"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-item-required x_ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_824006088" style=3D"">
<div class=3D"x_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"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
*</span>
</div>
<div class=3D"x_ss-q-help x_ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"x_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%">
Sat 95% Fc 70 Estertores gruesos en ambos campos pulmonares M 0 en extremidad superior izquierda M2 en extremidad inferior izquierda No presenta edema en extremidad inferior izquierda.</div>
</div>
</div>
</div>
<br>
<div class=3D"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-item-required x_ss-text" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_1690694733" style=3D"">
<div class=3D"x_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"">
</label>
<span class=3D"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
*</span>
</div>
<div class=3D"x_ss-q-help x_ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
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</label>
<div class=3D"x_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%">
Tumor cerebral</div>
</div>
</div>
</div>
<br>
<div class=3D"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-item-required x_ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_1255665248" style=3D"">
<div class=3D"x_ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Plan de Tratamiento e Indicaciones <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
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<span class=3D"x_ss-required-asterisk" aria-hidden=3D"true" style==3D"color:#c43b1d">
*</span>
</div>
<div class=3D"x_ss-q-help x_ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"x_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%">
Fisioterapia, Ktr, Ktm </div>
</div>
</div>
</div>
<br>
<div class=3D"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_1648939075" style=3D"">
<div class=3D"x_ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Medicamentos Indicados </div>
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</div>
</label>
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</div>
</div>
<br>
<div class=3D"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-date" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_2063615873" style=3D"">
<div class=3D"x_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"x_ss-q-help x_ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"x_ss-q-date" role=3D"group" aria-label=3D"Fecha aproximada del Pr=F3ximo Control con usted  " style=3D"">
<div class=3D"x_ss-datetime-box x_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"x_entry.2063615873_day" disabled=3D"" class=3D"x_ss-day-dropdown" id=3D"x_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>
 <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" selected=3D"" 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" 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"x_entry.2063615873_month" disabled=3D"" class=3D"x_ss-month-dropdown" id=3D"x_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>
 <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" style=3D"">
junio</option>
 <option value=3D"7" selected=3D"" 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"x_entry.2063615873_year" disabled=3D"" id=3D"x_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"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-text" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_74766472" style=3D"">
<div class=3D"x_ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Tratamiento Realizado (si corresponde) </div>
<div class=3D"x_ss-q-help x_ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"x_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%">
Fisioterapia, ktr, ktm </div>
</div>
</div>
</div>
<br>
<div class=3D"x_ss-form-question x_errorbox-good" role=3D"listitem" style==3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-checkbox" style=3D"margin:12px 0">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"x_ss-q-item-label" for=3D"entry_1219705969" style=3D"">
<div class=3D"x_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"x_ss-q-help x_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>
</label>
<ul class=3D"x_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">
<li class=3D"x_ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"x_ss-choice-item-control x_goog-inline-block" style==3D"display:inline-block">
<input type=3D"checkbox" name=3D"x_entry.503039759" disabled=3D"" value=3D"ENFERMERA" id=3D"x_group_503039759_1" role=3D"checkbox" class=3D"x_ss-q-checkbox" style=3D"">
</span>
<span class=3D"x_ss-choice-label" style=3D"">
ENFERMERA</span>
 </label>
</li>
<li class=3D"x_ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"x_ss-choice-item-control x_goog-inline-block" style==3D"display:inline-block">
<input type=3D"checkbox" name=3D"x_entry.503039759" disabled=3D"" value=3D"TENS" id=3D"x_group_503039759_2" role=3D"checkbox" class=3D"x_ss-q-checkbox" style=3D"">
</span>
<span class=3D"x_ss-choice-label" style=3D"">
TENS</span>
 </label>
</li>
<li class=3D"x_ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"x_ss-choice-item-control x_goog-inline-block" style==3D"display:inline-block">
<input type=3D"checkbox" name=3D"x_entry.503039759" disabled=3D"" value=3D"NUTRICIONISTA" id=3D"x_group_503039759_3" role=3D"checkbox" class=3D"x_ss-q-checkbox" style=3D"">
</span>
<span class=3D"x_ss-choice-label" style=3D"">
NUTRICIONISTA</span>
 </label>
</li>
<li class=3D"x_ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"x_ss-choice-item-control x_goog-inline-block" style==3D"display:inline-block">
<input type=3D"checkbox" name=3D"x_entry.503039759" disabled=3D"" value=3D"KINESIOLOGO" id=3D"x_group_503039759_4" role=3D"checkbox" class=3D"x_ss-q-checkbox" style=3D"">
</span>
<span class=3D"x_ss-choice-label" style=3D"">
KINESIOLOGO</span>
 </label>
</li>
<li class=3D"x_ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"x_ss-choice-item-control x_goog-inline-block" style==3D"display:inline-block">
<input type=3D"checkbox" name=3D"x_entry.503039759" disabled=3D"" value=3D"PSICOLOGO" id=3D"x_group_503039759_5" role=3D"checkbox" class=3D"x_ss-q-checkbox" style=3D"">
</span>
<span class=3D"x_ss-choice-label" style=3D"">
PSICOLOGO</span>
 </label>
</li>
</ul>
</div>
</div>
</div>
<br>
<div class=3D"x_errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"x_ss-item x_ss-embeddable-object-container" style=3D"margin:12px 0; max-width:100%">
<div class=3D"x_ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"x_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"x_ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A">
</div>
</div>
</div>
</div>
<br>
</form>
</div>
</div>
</td>
</tr>
<tr height=3D"24px">
</tr>
</tbody>
</table>
</div>
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%" role=3D"presentation" style=3D"max-width:672px; min-width:154px">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242; font-size:13px">
Crea tu propio formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</body>
</html>
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