<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">
Nilqger Garcia</strong>
 <span dir=3D"auto">
&lt;<a href=3D"mailto:nilqgergarcia@gmail.com">
nilqgergarcia@gmail.com</a>
&gt;</span>
<br>
Date: vie., 2 ago. 2019 19:54<br>
Subject: Fwd: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:informeges@telemed-chile.cl">
informeges@telemed-chile.cl</a>
&gt;,  &lt;<a href=3D"mailto:f.salinas.1987.fs@gmail.com">
f.salinas.1987.fs@gmail.com</a>
&gt;, Evelyn Ortega &lt;<a href=3D"mailto:Eveortegaa@gmail.com">
Eveortegaa@gmail.com</a>
&gt;, Nilqger Garcia &lt;<a href=3D"mailto:nilqgergarcia@gmail.com">
nilqgergarcia@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div dir=3D"ltr">
<br>
isabel general 1 d e=C2=A0 agosto talca por dra nilqger garcia<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class=3D"gmail_attr">
---------- Forwarded message ---------<br>
From: <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" target=3D"_blank" rel=3D"noreferrer">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: Fri, Aug 2, 2019 at 7:53 PM<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:nilqgergarcia@gmail.com" target=3D"_blank" rel=3D"noreferrer">
nilqgergarcia@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 llenar <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">
Estas son tus respuestas:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-container">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-heading">
<h1 class=3D"m_7018468099196835043m_630539202923608210ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-desc m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-form">
<form method=3D"GET" id=3D"m_7018468099196835043m_630539202923608210ss-form" target=3D"_blank">
<br>
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-text" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for==3D"m_7018468099196835043m_630539202923608210emailAddress">
<div class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210emailAddress">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-text m_7018468099196835043m_630539202923608210ss-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:nilqgergarcia@gmail.com" target=3D"_blank" rel=3D"noreferrer">
nilqgergarcia@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/00-FWRRIiJNpjLIXj1QrTLVceHhiPxWpIN-K4cI0enEtAvmFFnvOHRJTMz5Lq8yFpMHz7WvBnNdiNVchE6Snklpxxc7gIx3OoqTfn_sB2_iSp_6sx7Sr2pww-0pD" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_7018468099196835043m_630539202923608210ss-page-title" style==3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_7018468099196835043m_630539202923608210ss-page-description m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-text" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_579114469">
<div class==3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_7018468099196835043m_630539202923608210itemView.getDomIdToLabel()">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_7018468099196835043m_630539202923608210ss-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%">
nilqger garcia</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-text" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_1276273985">
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_7018468099196835043m_630539202923608210itemView.getDomIdToLabel()">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-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%">
25742995-4</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-select" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_133691676">
<div class==3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_7018468099196835043m_630539202923608210itemView.getDomIdToLabel()">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled selected>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/mRJInQVKRU12r9blREv2jmlzETLT9JfIHWC0FaeXYfPraPFE9ebBRX8P_hmpfiBP6BNpOgjPBYU0zwBxYxgoLvjQ7EjfjoRTJ2_-8flTaiU_wC008XC8LpcEJ_Yp" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_7018468099196835043m_630539202923608210ss-page-title" style==3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_7018468099196835043m_630539202923608210ss-page-description m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_7018468099196835043m_630539202923608210ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_7018468099196835043m_630539202923608210ss-section-description m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-text" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_823811303">
<div class==3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_7018468099196835043m_630539202923608210itemView.getDomIdToLabel()">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-text" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_1959365839">
<div class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210itemView.getDomIdToLabel()">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-select" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_545002227">
<div class==3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_7018468099196835043m_630539202923608210itemView.getDomIdToLabel()">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210entry_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_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-text" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_1900161356">
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_7018468099196835043m_630539202923608210itemView.getDomIdToLabel()">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-text" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_1298871758">
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_7018468099196835043m_630539202923608210itemView.getDomIdToLabel()">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/URytM0QWRGW_JEL0xQxvOLvwPRJIHyqlnKOm6ky9DRBfzvYVPaAngXV35GNHnaVG-dm9Orno4lr8sy8E-KB9tMrmIhFbVQiOPWy3vUclqRKAJ51dvLdhjBKgXdLO" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_7018468099196835043m_630539202923608210ss-page-title" style==3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_7018468099196835043m_630539202923608210ss-page-description m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-radio" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_2073233714">
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci==C3=B3n<label for=3D"m_7018468099196835043m_630539202923608210itemView.getDomIdToLabel()">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_7018468099196835043m_630539202923608210ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_7018468099196835043m_630539202923608210ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-choice-item-control m_7018468099196835043m_630539202923608210goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_7018468099196835043m_630539202923608210group_1222378237_1" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</span>
<span class=3D"m_7018468099196835043m_630539202923608210ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_7018468099196835043m_630539202923608210ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-choice-item-control m_7018468099196835043m_630539202923608210goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_7018468099196835043m_630539202923608210group_1222378237_2" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</span>
<span class=3D"m_7018468099196835043m_630539202923608210ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-date" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_1705849412">
<div class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210itemView.getDomIdToLabel()">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-date">
<div class=3D"m_7018468099196835043m_630539202923608210ss-datetime-box m_7018468099196835043m_630539202923608210goog-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_month" disabled class=3D"m_7018468099196835043m_630539202923608210ss-month-dropdown" id=3D"m_7018468099196835043m_630539202923608210entry.1705849412_month">
<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
 <option value=3D"2">
febrero</option>
 <option value=3D"3">
marzo</option>
 <option value=3D"4">
abril</option>
 <option value=3D"5">
mayo</option>
 <option value=3D"6">
junio</option>
 <option value==3D"7">
julio</option>
 <option value=3D"8" selected>
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>
   <select name=3D"entry.1705849412_day" disabled class=3D"m_7018468099196835043m_630539202923608210ss-day-dropdown" id=3D"m_7018468099196835043m_630539202923608210entry.1705849412_day">
<option value=3D"">
D=C3=ADa</option>
<option value=3D"1" selected>
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>
 <option value=3D"8">
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">
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>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_7018468099196835043m_630539202923608210entry.1705849412_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
 <option value=3D"1898">
1898</option>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
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>
 <option value=3D"1937">
1937</option>
 <option value==3D"1938">
1938</option>
 <option value=3D"1939">
1939</option>
 <option value==3D"1940">
1940</option>
 <option value=3D"1941">
1941</option>
 <option value==3D"1942">
1942</option>
 <option value=3D"1943">
1943</option>
 <option value==3D"1944">
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_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_206244955">
<div class==3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210itemView.getDomIdToLabel()">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-time">
<div class=3D"m_7018468099196835043m_630539202923608210ss-datetime-box m_7018468099196835043m_630539202923608210goog-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_7018468099196835043m_630539202923608210entry.206244955_hour">
<option value=3D"">
h</option>
<option value=3D"00">
00</option>
 <option value=3D"01">
01</option>
 <option value=3D"02">
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">
16</option>
 <option value=3D"17" selected>
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>
</select>
.<select name=3D"entry.206244955_minute" disabled id=3D"m_7018468099196835043m_630539202923608210entry.206244955_minute">
<option value=3D"">
min</option>
<option value=3D"00" selected>
00</option>
 <option value=3D"01">
01</option>
 <option value=3D"02">
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">
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>
 <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>
 <option value=3D"32">
32</option>
 <option value=3D"33">
33</option>
 <option value=3D"34">
34</option>
 <option value=3D"35">
35</option>
 <option value=3D"36">
36</option>
 <option value=3D"37">
37</option>
 <option value=3D"38">
38</option>
 <option value=3D"39">
39</option>
 <option value=3D"40">
40</option>
 <option value=3D"41">
41</option>
 <option value=3D"42">
42</option>
 <option value=3D"43">
43</option>
 <option value=3D"44">
44</option>
 <option value=3D"45">
45</option>
 <option value=3D"46">
46</option>
 <option value=3D"47">
47</option>
 <option value=3D"48">
48</option>
 <option value=3D"49">
49</option>
 <option value=3D"50">
50</option>
 <option value=3D"51">
51</option>
 <option value=3D"52">
52</option>
 <option value=3D"53">
53</option>
 <option value=3D"54">
54</option>
 <option value=3D"55">
55</option>
 <option value=3D"56">
56</option>
 <option value=3D"57">
57</option>
 <option value=3D"58">
58</option>
 <option value=3D"59">
59</option>
</select>
<div class=3D"m_7018468099196835043m_630539202923608210ss-datetime-box-spacer m_7018468099196835043m_630539202923608210goog-inline-block" style=3D"height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-select" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_1747608258">
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_7018468099196835043m_630539202923608210itemView.getDomIdToLabel()">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.1747608258" disabled id=3D"m_7018468099196835043m_630539202923608210entry_1747608258">
<option value=3D"">
</option>
<option value=3D"0" disabled>
0</option>
 <option value=3D"1" disabled selected>
1</option>
 <option value=3D"2" disabled>
2</option>
 <option value=3D"3" disabled>
3</option>
 <option value=3D"4" disabled>
4</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_1716090865">
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210entry_1421689035">
<tbody>
<tr>
<td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1421689035_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_7018468099196835043m_630539202923608210ss-scalerow m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210aria-todo">
</div>
</td>
<td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled checked value=3D"0" id=3D"m_7018468099196835043m_630539202923608210group_1421689035_1" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"1" id=3D"m_7018468099196835043m_630539202923608210group_1421689035_2" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"2" id=3D"m_7018468099196835043m_630539202923608210group_1421689035_3" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3" id=3D"m_7018468099196835043m_630539202923608210group_1421689035_4" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_7018468099196835043m_630539202923608210group_1421689035_5" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_7018468099196835043m_630539202923608210group_1421689035_6" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_7018468099196835043m_630539202923608210group_1421689035_7" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value==3D"7" id=3D"m_7018468099196835043m_630539202923608210group_1421689035_8" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_7018468099196835043m_630539202923608210group_1421689035_9" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name==3D"entry.1421689035" disabled value=3D"9" id=3D"m_7018468099196835043m_630539202923608210group_1421689035_10" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"10" id=3D"m_7018468099196835043m_630539202923608210group_1421689035_11" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
<td class=3D"m_7018468099196835043m_630539202923608210ss-scalerow m_7018468099196835043m_630539202923608210ss-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>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_2064050596">
<div class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210entry_1244707512">
<tbody>
<tr>
<td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_7018468099196835043m_630539202923608210ss-scalerow m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210aria-todo">
</div>
</td>
<td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"0" id=3D"m_7018468099196835043m_630539202923608210group_1244707512_1" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"1" id=3D"m_7018468099196835043m_630539202923608210group_1244707512_2" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"2" id=3D"m_7018468099196835043m_630539202923608210group_1244707512_3" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled checked value=3D"3" id=3D"m_7018468099196835043m_630539202923608210group_1244707512_4" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"4" id=3D"m_7018468099196835043m_630539202923608210group_1244707512_5" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"5" id=3D"m_7018468099196835043m_630539202923608210group_1244707512_6" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"6" id=3D"m_7018468099196835043m_630539202923608210group_1244707512_7" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value==3D"7" id=3D"m_7018468099196835043m_630539202923608210group_1244707512_8" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"8" id=3D"m_7018468099196835043m_630539202923608210group_1244707512_9" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name==3D"entry.1244707512" disabled value=3D"9" id=3D"m_7018468099196835043m_630539202923608210group_1244707512_10" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"10" id=3D"m_7018468099196835043m_630539202923608210group_1244707512_11" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
<td class=3D"m_7018468099196835043m_630539202923608210ss-scalerow m_7018468099196835043m_630539202923608210ss-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>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_2000523015">
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=ADnimo</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210entry_853118630">
<tbody>
<tr>
<td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_853118630_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_853118630_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_853118630_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_853118630_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_853118630_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_853118630_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_853118630_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_853118630_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_853118630_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_853118630_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_7018468099196835043m_630539202923608210ss-scalenumber" for=3D"m_7018468099196835043m_630539202923608210group_853118630_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_7018468099196835043m_630539202923608210ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_7018468099196835043m_630539202923608210ss-scalerow m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210aria-todo">
</div>
</td>
<td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"0" id=3D"m_7018468099196835043m_630539202923608210group_853118630_1" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name==3D"entry.853118630" disabled checked value=3D"1" id=3D"m_7018468099196835043m_630539202923608210group_853118630_2" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"2" id=3D"m_7018468099196835043m_630539202923608210group_853118630_3" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value==3D"3" id=3D"m_7018468099196835043m_630539202923608210group_853118630_4" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"4" id=3D"m_7018468099196835043m_630539202923608210group_853118630_5" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"5" id=3D"m_7018468099196835043m_630539202923608210group_853118630_6" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"6" id=3D"m_7018468099196835043m_630539202923608210group_853118630_7" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"7" id=3D"m_7018468099196835043m_630539202923608210group_853118630_8" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"8" id=3D"m_7018468099196835043m_630539202923608210group_853118630_9" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"9" id=3D"m_7018468099196835043m_630539202923608210group_853118630_10" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
 <td class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"10" id=3D"m_7018468099196835043m_630539202923608210group_853118630_11" class=3D"m_7018468099196835043m_630539202923608210ss-q-radio">
</div>
</td>
<td class=3D"m_7018468099196835043m_630539202923608210ss-scalerow m_7018468099196835043m_630539202923608210ss-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>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_2140974612">
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Anamnesis/Evoluci=C3=B3n<label for=3D"m_7018468099196835043m_630539202923608210itemView.getDomIdToLabel()">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_7018468099196835043m_630539202923608210ss-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 diagnosticada con c=C3=A1ncer d e colon metast=C3=A1sico sin colostom=C3=ADa, en actual estadiaje quien va a santiago la semana entrante a colocar cat=C3=A9ter d e quimioterapia quien inicia enfermedad actual hace un mes aproximadamente con rectorragia y cl=C3=ADnica d e hemorragia digestiva superior por lo que la ingresan hacen diagnostico y transfunden. paracl=C3=ADnicos reportan adenocarcinoma tubular ulcerado con necrosis extensa en recto, calcio 9.3, alb 3.9, glic 121, hb 8.8, plaquetas 420000. actualmente presenta poca rectorragia eventualmente, un episodio de hematemesis el dia del ingreso, nauseas niega, debilidad, fiebre niega. evacuaciones diarias frecuentes, prurito niega, apetito bueno animo conservado, diuresis conservada. dentro d elos antecedentes de importancia diabetes insulino requiriente en tto con lantus 24 unidades y novorapid, hipertensa en tto, niega alergias. epil=C3=A9ptica en tto.paciente en quimioterapia. dolor eva maximo 4 ptos . se indico buprenorfina 7 mcg/hora cada 3 dias y tramal 10 gotas cada 12 horas. refiere melena eventual.actualmente recibiendo quimioterapia de 5 fluoracilo por bomba de infusi=C3=B3n <a href=3D"http://continua.se" target=3D"_blank" rel==3D"noreferrer">
continua.se</a>
 evidencia ritmo irregularmente irregular durante el examen fisico, con extrasistoles frecuentes, por lo que se supone cardiotoxicidad asociada a la QMT. Se indica a cudir a urgencias de clinica lircay para ser valorada e instaurar tto antiarritmico, asi como realizara ajuste de QMT</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_824006088">
<div class==3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen F=C3=ADsico<label for=3D"m_7018468099196835043m_630539202923608210itemView.getDomIdToLabel()">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_7018468099196835043m_630539202923608210ss-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 con palidez cut=C3=A1neo mucosa moderada, pulmonar ruidos respiratorios presentes en ambos campos pulmonares sin agregados, cv ruidos card=C3=ADacos arr=C3=ADtmicos irregulares sin soplos. abdomen blando depresible. 132/89 , fc entre 72 y 75 sato2 99 temp 37. aparente buenas condiciones generale, asintomatica recibiendo quimioterpaia por bomba. niega nauseas, vomitos, mareos o disnea u otro sintomas. hemodinamicamente estable</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-text" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_1690694733">
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_7018468099196835043m_630539202923608210itemView.getDomIdToLabel()">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_7018468099196835043m_630539202923608210ss-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%">
c=C3=A1ncer de colon en estadiaje</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-item-required m_7018468099196835043m_630539202923608210ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_1255665248">
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_7018468099196835043m_630539202923608210itemView.getDomIdToLabel()">
</label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_7018468099196835043m_630539202923608210ss-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%">
continuar tto medico y acudir a urgencias por arritmia actual de nueva aparicion. control con cardi=C3=B3logo y onc=C3=B3logo m=C3=A9dico</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_1648939075">
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-date" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_2063615873">
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-date">
<div class=3D"m_7018468099196835043m_630539202923608210ss-datetime-box m_7018468099196835043m_630539202923608210goog-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.2063615873_month" disabled class=3D"m_7018468099196835043m_630539202923608210ss-month-dropdown" id=3D"m_7018468099196835043m_630539202923608210entry.2063615873_month">
<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
 <option value=3D"2">
febrero</option>
 <option value=3D"3">
marzo</option>
 <option value=3D"4">
abril</option>
 <option value=3D"5">
mayo</option>
 <option value=3D"6">
junio</option>
 <option value==3D"7">
julio</option>
 <option value=3D"8" selected>
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>
   <select name=3D"entry.2063615873_day" disabled class=3D"m_7018468099196835043m_630539202923608210ss-day-dropdown" id=3D"m_7018468099196835043m_630539202923608210entry.2063615873_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" selected>
6</option>
 <option value=3D"7">
7</option>
 <option value=3D"8">
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">
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>
=20<select name=3D"entry.2063615873_year" disabled id=3D"m_7018468099196835043m_630539202923608210entry.2063615873_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
 <option value=3D"1898">
1898</option>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
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>
 <option value=3D"1937">
1937</option>
 <option value==3D"1938">
1938</option>
 <option value=3D"1939">
1939</option>
 <option value==3D"1940">
1940</option>
 <option value=3D"1941">
1941</option>
 <option value==3D"1942">
1942</option>
 <option value=3D"1943">
1943</option>
 <option value==3D"1944">
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_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-text" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_74766472">
<div class==3D"m_7018468099196835043m_630539202923608210ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_7018468099196835043m_630539202923608210ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210ss-form-question m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_7018468099196835043m_630539202923608210ss-q-item-label" for=3D"m_7018468099196835043m_630539202923608210entry_1219705969">
<div class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-q-help m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_7018468099196835043m_630539202923608210ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-choice-item-control m_7018468099196835043m_630539202923608210goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"ENFERMERA" id=3D"m_7018468099196835043m_630539202923608210group_503039759_1" class=3D"m_7018468099196835043m_630539202923608210ss-q-checkbox">
</span>
<span class=3D"m_7018468099196835043m_630539202923608210ss-choice-label">
ENFERMERA</span>
</label>
</li>
 <li class=3D"m_7018468099196835043m_630539202923608210ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-choice-item-control m_7018468099196835043m_630539202923608210goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_7018468099196835043m_630539202923608210group_503039759_2" class=3D"m_7018468099196835043m_630539202923608210ss-q-checkbox">
</span>
<span class=3D"m_7018468099196835043m_630539202923608210ss-choice-label">
TENS</span>
</label>
</li>
 <li class=3D"m_7018468099196835043m_630539202923608210ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-choice-item-control m_7018468099196835043m_630539202923608210goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id=3D"m_7018468099196835043m_630539202923608210group_503039759_3" class=3D"m_7018468099196835043m_630539202923608210ss-q-checkbox">
</span>
<span class=3D"m_7018468099196835043m_630539202923608210ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
 <li class=3D"m_7018468099196835043m_630539202923608210ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-choice-item-control m_7018468099196835043m_630539202923608210goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"KINESIOLOGO" id=3D"m_7018468099196835043m_630539202923608210group_503039759_4" class=3D"m_7018468099196835043m_630539202923608210ss-q-checkbox">
</span>
<span class=3D"m_7018468099196835043m_630539202923608210ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
 <li class=3D"m_7018468099196835043m_630539202923608210ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_7018468099196835043m_630539202923608210ss-choice-item-control m_7018468099196835043m_630539202923608210goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"PSICOLOGO" id=3D"m_7018468099196835043m_630539202923608210group_503039759_5" class=3D"m_7018468099196835043m_630539202923608210ss-q-checkbox">
</span>
<span class=3D"m_7018468099196835043m_630539202923608210ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_7018468099196835043m_630539202923608210errorbox-good">
<div dir=3D"auto" class=3D"m_7018468099196835043m_630539202923608210ss-item m_7018468099196835043m_630539202923608210ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_7018468099196835043m_630539202923608210ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_7018468099196835043m_630539202923608210ss-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_7018468099196835043m_630539202923608210ss-image" title=3D"" src=3D"https://lh5.googleusercontent.com/Bpur5zPteyG-bXtM-WNRuiLwTi8myvetX7lBkdjzbnQyqUlGcuv84zmWyU3x0Ua2-_WXX9PiJ2cMBOO0zhG2nHX7tXXPHH6_X8UTG8MZzIBwxETkF0a8JyZtuxSL" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</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">
Crear tu propio Formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div>
--0000000000002d5d65058faffcfd--