<div dir=3D"auto">
</div>
<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">
Formularios de Google</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: dom., 21 jul. 2019 16:37<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:eveortegaa@gmail.com">
eveortegaa@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Formularios de Google" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por rellenar <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target=3D"_blank" rel=3D"noreferrer">
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">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_4705218851049790497ss-form-container">
<div class=3D"m_4705218851049790497ss-form-heading">
<h1 class=3D"m_4705218851049790497ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_4705218851049790497ss-form-desc m_4705218851049790497ss-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_4705218851049790497ss-form">
<form method=3D"GET" id=3D"m_4705218851049790497ss-form" target=3D"_blank">
<br>
<div class=3D"m_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-item-required m_4705218851049790497ss-text" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497emailAddress">
<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Direcci=C3==B3n de correo electr=C3=B3nico<label for=3D"m_4705218851049790497emailAddress">
</label>
<span class=3D"m_4705218851049790497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_4705218851049790497ss-q-text m_4705218851049790497ss-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:eveortegaa@gmail.com" target=3D"_blank" rel=3D"noreferrer">
eveortegaa@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_4705218851049790497ss-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_4705218851049790497ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_4705218851049790497ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_4705218851049790497ss-page-description m_4705218851049790497ss-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_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-item-required m_4705218851049790497ss-text" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_579114469">
<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_4705218851049790497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4705218851049790497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_4705218851049790497ss-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%">
Evelyn Ortega </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-item-required m_4705218851049790497ss-text" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_1276273985">
<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_4705218851049790497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4705218851049790497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-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_4705218851049790497ss-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%">
16273226-9</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-item-required m_4705218851049790497ss-select" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_133691676">
<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_4705218851049790497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4705218851049790497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-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_4705218851049790497entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled selected>
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_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_4705218851049790497ss-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_4705218851049790497ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_4705218851049790497ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_4705218851049790497ss-page-description m_4705218851049790497ss-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_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_4705218851049790497ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_4705218851049790497ss-section-description m_4705218851049790497ss-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_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-item-required m_4705218851049790497ss-text" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_823811303">
<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_4705218851049790497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4705218851049790497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-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_4705218851049790497ss-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%">
7558632-9</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-item-required m_4705218851049790497ss-text" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_1959365839">
<div class=3D"m_4705218851049790497ss-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_4705218851049790497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4705218851049790497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_4705218851049790497ss-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%">
Isabel General</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-item-required m_4705218851049790497ss-select" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_545002227">
<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_4705218851049790497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4705218851049790497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-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_4705218851049790497entry_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 selected>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled>
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled>
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-item-required m_4705218851049790497ss-text" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_1900161356">
<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_4705218851049790497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4705218851049790497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_4705218851049790497ss-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%">
Talca</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-item-required m_4705218851049790497ss-text" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_1298871758">
<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_4705218851049790497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4705218851049790497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_4705218851049790497ss-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%">
Talca</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_4705218851049790497ss-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_4705218851049790497ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_4705218851049790497ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_4705218851049790497ss-page-description m_4705218851049790497ss-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_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-item-required m_4705218851049790497ss-radio" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_2073233714">
<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_4705218851049790497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4705218851049790497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_4705218851049790497ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_4705218851049790497ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_4705218851049790497ss-choice-item-control m_4705218851049790497goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_4705218851049790497group_1222378237_1" class=3D"m_4705218851049790497ss-q-radio">
</span>
<span class=3D"m_4705218851049790497ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_4705218851049790497ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_4705218851049790497ss-choice-item-control m_4705218851049790497goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_4705218851049790497group_1222378237_2" class=3D"m_4705218851049790497ss-q-radio">
</span>
<span class=3D"m_4705218851049790497ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-item-required m_4705218851049790497ss-date" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_1705849412">
<div class=3D"m_4705218851049790497ss-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_4705218851049790497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4705218851049790497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_4705218851049790497ss-q-date">
<div class=3D"m_4705218851049790497ss-datetime-box m_4705218851049790497goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name=3D"entry.1705849412_day" disabled class=3D"m_4705218851049790497ss-day-dropdown" id=3D"m_4705218851049790497entry.1705849412_day">
<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
 <option value=3D"2">
2</option>
 <option value=3D"3">
3</option>
 <option value=3D"4">
4</option>
 <option value=3D"5">
5</option>
 <option value=3D"6">
6</option>
 <option value=3D"7">
7</option>
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8</option>
 <option value=3D"9">
9</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value==3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20" selected>
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
</select>
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<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
 <option value=3D"2">
febrero</option>
 <option value=3D"3">
marzo</option>
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abril</option>
 <option value=3D"5">
mayo</option>
 <option value=3D"6">
junio</option>
 <option value==3D"7" selected>
julio</option>
 <option value=3D"8">
agosto</option>
 <option value=3D"9">
septiembre</option>
 <option value=3D"10">
octubre</option>
 <option value=3D"11">
noviembre</option>
 <option value=3D"12">
diciembre</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_4705218851049790497entry.1705849412_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
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1897</option>
 <option value=3D"1898">
1898</option>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
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1901</option>
 <option value=3D"1902">
1902</option>
 <option value=3D"1903">
1903</option>
 <option value=3D"1904">
1904</option>
 <option value=3D"1905">
1905</option>
 <option value=3D"1906">
1906</option>
 <option value=3D"1907">
1907</option>
 <option value=3D"1908">
1908</option>
 <option value=3D"1909">
1909</option>
 <option value=3D"1910">
1910</option>
 <option value=3D"1911">
1911</option>
 <option value=3D"1912">
1912</option>
 <option value=3D"1913">
1913</option>
 <option value=3D"1914">
1914</option>
 <option value=3D"1915">
1915</option>
 <option value=3D"1916">
1916</option>
 <option value=3D"1917">
1917</option>
 <option value=3D"1918">
1918</option>
 <option value=3D"1919">
1919</option>
 <option value=3D"1920">
1920</option>
 <option value=3D"1921">
1921</option>
 <option value=3D"1922">
1922</option>
 <option value=3D"1923">
1923</option>
 <option value==3D"1924">
1924</option>
 <option value=3D"1925">
1925</option>
 <option value==3D"1926">
1926</option>
 <option value=3D"1927">
1927</option>
 <option value==3D"1928">
1928</option>
 <option value=3D"1929">
1929</option>
 <option value==3D"1930">
1930</option>
 <option value=3D"1931">
1931</option>
 <option value==3D"1932">
1932</option>
 <option value=3D"1933">
1933</option>
 <option value==3D"1934">
1934</option>
 <option value=3D"1935">
1935</option>
 <option value==3D"1936">
1936</option>
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1937</option>
 <option value==3D"1938">
1938</option>
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1939</option>
 <option value==3D"1940">
1940</option>
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1941</option>
 <option value==3D"1942">
1942</option>
 <option value=3D"1943">
1943</option>
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1944</option>
 <option value=3D"1945">
1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
1948</option>
 <option value=3D"1949">
1949</option>
 <option value==3D"1950">
1950</option>
 <option value=3D"1951">
1951</option>
 <option value==3D"1952">
1952</option>
 <option value=3D"1953">
1953</option>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
 <option value=3D"1959">
1959</option>
 <option value==3D"1960">
1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
1976</option>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
 <option value==3D"1980">
1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
 <option value=3D"2011">
2011</option>
 <option value==3D"2012">
2012</option>
 <option value=3D"2013">
2013</option>
 <option value==3D"2014">
2014</option>
 <option value=3D"2015">
2015</option>
 <option value==3D"2016">
2016</option>
 <option value=3D"2017">
2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-item-required m_4705218851049790497ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_206244955">
<div class=3D"m_4705218851049790497ss-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_4705218851049790497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4705218851049790497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_4705218851049790497ss-q-time">
<div class=3D"m_4705218851049790497ss-datetime-box m_4705218851049790497goog-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_4705218851049790497entry.206244955_hour">
<option value=3D"">
h</option>
<option value=3D"00">
00</option>
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01</option>
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02</option>
 <option value=3D"03">
03</option>
 <option value=3D"04">
04</option>
 <option value=3D"05">
05</option>
 <option value=3D"06">
06</option>
 <option value=3D"07">
07</option>
 <option value=3D"08">
08</option>
 <option value=3D"09">
09</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16" selected>
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value==3D"22">
22</option>
 <option value=3D"23">
23</option>
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</div>
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</div>
</div>
</div>
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<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
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<span class=3D"m_4705218851049790497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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0</option>
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1</option>
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2</option>
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3</option>
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4</option>
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</div>
</div>
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 <div class=3D"m_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_1716090865">
<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-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_4705218851049790497entry_1421689035">
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<td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
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<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1421689035_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
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<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
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<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
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<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
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<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
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</div>
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</div>
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<div class=3D"m_4705218851049790497ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_4705218851049790497group_1421689035_7" class=3D"m_4705218851049790497ss-q-radio">
</div>
</td>
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</div>
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</div>
</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_4705218851049790497group_1421689035_10" class=3D"m_4705218851049790497ss-q-radio">
</div>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"10" id=3D"m_4705218851049790497group_1421689035_11" class=3D"m_4705218851049790497ss-q-radio">
</div>
</td>
<td class=3D"m_4705218851049790497ss-scalerow m_4705218851049790497ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_2064050596">
<div class=3D"m_4705218851049790497ss-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_4705218851049790497ss-q-help m_4705218851049790497ss-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_4705218851049790497entry_1244707512">
<tr>
<td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4705218851049790497ss-scalenumber" for=3D"m_4705218851049790497group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_4705218851049790497ss-scalerow m_4705218851049790497ss-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_4705218851049790497aria-todo">
</div>
</td>
<td class=3D"m_4705218851049790497ss-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_4705218851049790497ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"0" id=3D"m_4705218851049790497group_1244707512_1" class=3D"m_4705218851049790497ss-q-radio">
</div>
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</div>
</td>
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</td>
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</div>
</td>
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</div>
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</div>
</td>
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</div>
</td>
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</div>
</td>
<td class=3D"m_4705218851049790497ss-scalerow m_4705218851049790497ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_2000523015">
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Escala Dolor EVA M=C3=ADnimo</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
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0</label>
</td>
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1</label>
</td>
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2</label>
</td>
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3</label>
</td>
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4</label>
</td>
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5</label>
</td>
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6</label>
</td>
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7</label>
</td>
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8</label>
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9</label>
</td>
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10</label>
</td>
<td class=3D"m_4705218851049790497ss-scalenumbers" style=3D"text-align:center">
</td>
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<tr>
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<div class=3D"m_4705218851049790497aria-todo">
</div>
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</div>
</td>
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</div>
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</div>
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</div>
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</div>
</td>
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</div>
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</div>
</td>
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</div>
</td>
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</div>
</td>
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</div>
</td>
<td class=3D"m_4705218851049790497ss-scalerow m_4705218851049790497ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</table>
</div>
</div>
</div>
<br>
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<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_2140974612">
<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Anamnesis/Evoluci=C3=B3n<label for=3D"m_4705218851049790497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4705218851049790497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
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</div>
</label>
<div class=3D"m_4705218851049790497ss-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 orientada en tiempo y espacio, animo regular, segun su escala del dolor, deambula lento al interior de la casa, durante el dia permanece  varias horas del dia en cama ademas de la noche que no superan el 50%, satisfaciendo sus necesidades personales sola. Al momento de la visita refiere mucho dolor EVA 8/10Refiere que el dia 17 de julio 2019 inicia quimioterapia: OXALIPLATINO, 150.0 mg;  ACIDO FOLINICO, 700.0 mg; FLUOROURACILO, 700.0 mg; FLUOROURACILO INFUSION CONTINUA 4300.0 mg.=20Apetito: regularNauseas: (++) desde el miercolesVomitos: (+) desde el miercolesSue=C3=B1o: refiere que durante la noche se levanta de 3-4 veces para orinarDiuresis: (+)Deposiciones:(+) refiere que es acuosa y con dificultadPicazon; (+)Sangrado rectal: (-)Colicos: (+)Debilidad/cansancio: (-)Meteorismo:(-)Tos: (-)Dificultad respiratoria: (-)</div>
</div>
</div>
</div>
<br>
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<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_824006088">
<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
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</div>
</label>
<div class=3D"m_4705218851049790497ss-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%">
Al control de signos vitales:=20P/A: 129/79FC: 111T: 36.5Sat: 99Cabeza: Normocraneo, cabello cano corto, bien implantadoTorax: simetrico.Abdomen: blando, depresible y no doloroso a la palpacionExt superiores: movilesExt inferiores: moviles, edema (-), pulsos (+)Piel: indemne, tibia al tacto</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
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<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_1690694733">
<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_4705218851049790497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4705218851049790497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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Ca Colon</div>
</div>
</div>
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<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-item-required m_4705218851049790497ss-paragraph-text" style=3D"margin:12px 0">
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<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_4705218851049790497itemView.getDomIdToLabel()">
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1.- Control en 4 dias2.-Educacion farmacologica</div>
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</div>
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Medicamentos Indicados</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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1.-Omeprazol 20 mg cada 12 horas via oral2.-Paracetamol  1 gr cada 8 horas en caso de doloe3.- Tramal 5 gotas vo en caso de dolor4.- Carbamazepina5.- Losartan 2 al dia6.- Insulina Novorapid7.- Insulina tresiba 24 u8.- Neurobionta</div>
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Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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<div class=3D"m_4705218851049790497ss-q-date">
<div class=3D"m_4705218851049790497ss-datetime-box m_4705218851049790497goog-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"">
D=C3=ADa</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>
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<option value=3D"">
Mes</option>
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enero</option>
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febrero</option>
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marzo</option>
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abril</option>
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mayo</option>
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junio</option>
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julio</option>
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agosto</option>
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septiembre</option>
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noviembre</option>
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diciembre</option>
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A=C3=B1o</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>
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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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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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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>
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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>
 <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>
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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>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497ss-form-question m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-text" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_74766472">
<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_4705218851049790497ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
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<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4705218851049790497ss-q-item-label" for=3D"m_4705218851049790497entry_1219705969">
<div class=3D"m_4705218851049790497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_4705218851049790497ss-q-help m_4705218851049790497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
</label>
<ul class=3D"m_4705218851049790497ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_4705218851049790497ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_4705218851049790497ss-choice-item-control m_4705218851049790497goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"ENFERMERA" id=3D"m_4705218851049790497group_503039759_1" class=3D"m_4705218851049790497ss-q-checkbox">
</span>
<span class=3D"m_4705218851049790497ss-choice-label">
ENFERMERA</span>
</label>
</li>
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<label>
<span class=3D"m_4705218851049790497ss-choice-item-control m_4705218851049790497goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_4705218851049790497group_503039759_2" class=3D"m_4705218851049790497ss-q-checkbox">
</span>
<span class=3D"m_4705218851049790497ss-choice-label">
TENS</span>
</label>
</li>
 <li class=3D"m_4705218851049790497ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_4705218851049790497ss-choice-item-control m_4705218851049790497goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id==3D"m_4705218851049790497group_503039759_3" class=3D"m_4705218851049790497ss-q-checkbox">
</span>
<span class=3D"m_4705218851049790497ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
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<label>
<span class=3D"m_4705218851049790497ss-choice-item-control m_4705218851049790497goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"KINESIOLOGO" id=3D"m_4705218851049790497group_503039759_4" class=3D"m_4705218851049790497ss-q-checkbox">
</span>
<span class=3D"m_4705218851049790497ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
 <li class=3D"m_4705218851049790497ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_4705218851049790497ss-choice-item-control m_4705218851049790497goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"PSICOLOGO" id=3D"m_4705218851049790497group_503039759_5" class=3D"m_4705218851049790497ss-q-checkbox">
</span>
<span class=3D"m_4705218851049790497ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_4705218851049790497errorbox-good">
<div dir=3D"auto" class=3D"m_4705218851049790497ss-item m_4705218851049790497ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_4705218851049790497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_4705218851049790497ss-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_4705218851049790497ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
</form>
</div>
</div>
</td>
</tr>
<tr height=3D"24px">
</tr>
</tbody>
</table>
</div>
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"max-width:672px;min-width:154px" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242;font-size:13px" target=3D"_blank" rel=3D"noreferrer">
Crea tu propio formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
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