<div dir=3D"ltr">
<br>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class==3D"gmail_attr">
---------- Forwarded message ---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Google Forms</strong>
 <span dir=3D"ltr">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: s=C3=A1b., 11 may. 2019 a las 4:25<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:claudio.ravi94@gmail.com">
claudio.ravi94@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt==3D"Google Forms" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Thanks for filling out <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target==3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Here&#39;s what we got from you:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_-8340138587390601059ss-form-container">
<div class=3D"m_-8340138587390601059ss-form-heading">
<h1 class=3D"m_-8340138587390601059ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_-8340138587390601059ss-form-desc m_-8340138587390601059ss-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_-8340138587390601059ss-form">
<form method=3D"GET" id=3D"m_-8340138587390601059ss-form" target=3D"_blank">
<br>
<div class=3D"m_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-item-required m_-8340138587390601059ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059emailAddress">
<div class=3D"m_-8340138587390601059ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Email address<label for=3D"m_-8340138587390601059emailAddress">
</label>
<span class=3D"m_-8340138587390601059ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_-8340138587390601059ss-q-text m_-8340138587390601059ss-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:claudio.ravi94@gmail.com" target=3D"_blank">
claudio.ravi94@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8340138587390601059ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_-8340138587390601059ss-page-description m_-8340138587390601059ss-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_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-item-required m_-8340138587390601059ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_579114469">
<div class=3D"m_-8340138587390601059ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_-8340138587390601059itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8340138587390601059ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8340138587390601059ss-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%">
Claudio Ram=C3=ADrez </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-item-required m_-8340138587390601059ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_1276273985">
<div class=3D"m_-8340138587390601059ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_-8340138587390601059itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8340138587390601059ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-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_-8340138587390601059ss-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%">
18502492-k</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-item-required m_-8340138587390601059ss-select" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_133691676">
<div class=3D"m_-8340138587390601059ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_-8340138587390601059itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8340138587390601059ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-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_-8340138587390601059entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled>
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 selected>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8340138587390601059ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_-8340138587390601059ss-page-description m_-8340138587390601059ss-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_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8340138587390601059ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_-8340138587390601059ss-section-description m_-8340138587390601059ss-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_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-item-required m_-8340138587390601059ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_823811303">
<div class=3D"m_-8340138587390601059ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_-8340138587390601059itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8340138587390601059ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-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_-8340138587390601059ss-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%">
7966839-7</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-item-required m_-8340138587390601059ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_1959365839">
<div class=3D"m_-8340138587390601059ss-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_-8340138587390601059itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8340138587390601059ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8340138587390601059ss-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%">
Jose Leiva</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-item-required m_-8340138587390601059ss-select" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_545002227">
<div class=3D"m_-8340138587390601059ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_-8340138587390601059itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8340138587390601059ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-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_-8340138587390601059entry_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>
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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_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-item-required m_-8340138587390601059ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_1900161356">
<div class=3D"m_-8340138587390601059ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_-8340138587390601059itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8340138587390601059ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8340138587390601059ss-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%">
Antofagasta</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-item-required m_-8340138587390601059ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_1298871758">
<div class=3D"m_-8340138587390601059ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_-8340138587390601059itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8340138587390601059ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8340138587390601059ss-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%">
Antofagasta</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8340138587390601059ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_-8340138587390601059ss-page-description m_-8340138587390601059ss-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_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-item-required m_-8340138587390601059ss-radio" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_2073233714">
<div class=3D"m_-8340138587390601059ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_-8340138587390601059itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8340138587390601059ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_-8340138587390601059ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-8340138587390601059ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-8340138587390601059ss-choice-item-control m_-8340138587390601059goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_-8340138587390601059group_1222378237_1" class=3D"m_-8340138587390601059ss-q-radio">
</span>
<span class=3D"m_-8340138587390601059ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_-8340138587390601059ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-8340138587390601059ss-choice-item-control m_-8340138587390601059goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_-8340138587390601059group_1222378237_2" class=3D"m_-8340138587390601059ss-q-radio">
</span>
<span class=3D"m_-8340138587390601059ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-item-required m_-8340138587390601059ss-date" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_1705849412">
<div class=3D"m_-8340138587390601059ss-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_-8340138587390601059itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8340138587390601059ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8340138587390601059ss-q-date">
<div class=3D"m_-8340138587390601059ss-datetime-box m_-8340138587390601059goog-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_-8340138587390601059ss-month-dropdown" id=3D"m_-8340138587390601059entry.1705849412_month">
<option value==3D"">
Month</option>
<option value=3D"1">
January</option>
 <option value=3D"2">
February</option>
 <option value=3D"3">
March</option>
 <option value=3D"4">
April</option>
 <option value=3D"5" selected>
May</option>
 <option value=3D"6">
June</option>
 <option value=3D"7">
July</option>
 <option value=3D"8">
August</option>
 <option value=3D"9">
September</option>
 <option value=3D"10">
October</option>
 <option value=3D"11">
November</option>
 <option value=3D"12">
December</option>
</select>
   <select name=3D"entry.1705849412_day" disabled class=3D"m_-8340138587390601059ss-day-dropdown" id=3D"m_-8340138587390601059entry.1705849412_day">
<option value=3D"">
Day</option>
<option value=3D"1">
1</option>
 <option value=3D"2">
2</option>
 <option value=3D"3">
3</option>
 <option value=3D"4">
4</option>
 <option value=3D"5">
5</option>
 <option value=3D"6">
6</option>
 <option value=3D"7">
7</option>
 <option value=3D"8">
8</option>
 <option value=3D"9" selected>
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_-8340138587390601059entry.1705849412_year">
<option value=3D"">
Year</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_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-item-required m_-8340138587390601059ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_206244955">
<div class=3D"m_-8340138587390601059ss-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_-8340138587390601059itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8340138587390601059ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8340138587390601059ss-q-time">
<div class=3D"m_-8340138587390601059ss-datetime-box m_-8340138587390601059goog-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_-8340138587390601059entry.206244955_hour">
<option value=3D"">
Hr</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" selected>
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>
</select>
:<select name=3D"entry.206244955_minute" disabled id=3D"m_-8340138587390601059entry.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>
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11</option>
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22</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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32</option>
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33</option>
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34</option>
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35</option>
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36</option>
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37</option>
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38</option>
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39</option>
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40</option>
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41</option>
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42</option>
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43</option>
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44</option>
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45</option>
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46</option>
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47</option>
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48</option>
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49</option>
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50</option>
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51</option>
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52</option>
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53</option>
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54</option>
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55</option>
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56</option>
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57</option>
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58</option>
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59</option>
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<select name=3D"entry.206244955_ampm" disabled>
<option value=3D"AM">
AM</option>
<option value=3D"PM" selected>
PM</option>
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<div class=3D"m_-8340138587390601059ss-datetime-box-spacer m_-8340138587390601059goog-inline-block" style=3D"height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-item-required m_-8340138587390601059ss-select" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_1747608258">
<div class=3D"m_-8340138587390601059ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_-8340138587390601059itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8340138587390601059ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-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_-8340138587390601059entry_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_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_1716090865">
<div class=3D"m_-8340138587390601059ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-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_-8340138587390601059entry_1421689035">
<tbody>
<tr>
<td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1421689035_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1421689035_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-8340138587390601059ss-scalerow m_-8340138587390601059ss-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_-8340138587390601059aria-todo">
</div>
</td>
<td class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"0" id=3D"m_-8340138587390601059group_1421689035_1" class=3D"m_-8340138587390601059ss-q-radio">
</div>
</td>
 <td class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"1" id=3D"m_-8340138587390601059group_1421689035_2" class=3D"m_-8340138587390601059ss-q-radio">
</div>
</td>
 <td class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"2" id=3D"m_-8340138587390601059group_1421689035_3" class==3D"m_-8340138587390601059ss-q-radio">
</div>
</td>
 <td class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3" id=3D"m_-8340138587390601059group_1421689035_4" class=3D"m_-8340138587390601059ss-q-radio">
</div>
</td>
 <td class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_-8340138587390601059group_1421689035_5" class=3D"m_-8340138587390601059ss-q-radio">
</div>
</td>
 <td class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_-8340138587390601059group_1421689035_6" class=3D"m_-8340138587390601059ss-q-radio">
</div>
</td>
 <td class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_-8340138587390601059group_1421689035_7" class=3D"m_-8340138587390601059ss-q-radio">
</div>
</td>
 <td class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"7" id=3D"m_-8340138587390601059group_1421689035_8" class=3D"m_-8340138587390601059ss-q-radio">
</div>
</td>
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<div class=3D"m_-8340138587390601059ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_-8340138587390601059group_1421689035_9" class=3D"m_-8340138587390601059ss-q-radio">
</div>
</td>
 <td class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_-8340138587390601059group_1421689035_10" class=3D"m_-8340138587390601059ss-q-radio">
</div>
</td>
 <td class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"10" id=3D"m_-8340138587390601059group_1421689035_11" class=3D"m_-8340138587390601059ss-q-radio">
</div>
</td>
<td class=3D"m_-8340138587390601059ss-scalerow m_-8340138587390601059ss-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_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_2064050596">
<div class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-q-help m_-8340138587390601059ss-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_-8340138587390601059entry_1244707512">
<tbody>
<tr>
<td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1244707512_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1244707512_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8340138587390601059ss-scalenumber" for=3D"m_-8340138587390601059group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-8340138587390601059ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-8340138587390601059ss-scalerow m_-8340138587390601059ss-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_-8340138587390601059aria-todo">
</div>
</td>
<td class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"0" id=3D"m_-8340138587390601059group_1244707512_1" class=3D"m_-8340138587390601059ss-q-radio">
</div>
</td>
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Escala Dolor EVA M=C3=ADnimo</div>
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0</label>
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1</label>
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2</label>
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3</label>
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4</label>
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5</label>
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6</label>
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7</label>
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8</label>
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9</label>
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10</label>
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Anamnesis/Evoluci=C3=B3n<label for=3D"m_-8340138587390601059itemView.getDomIdToLabel()">
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*</span>
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El paciente se encuentra estable en cuanto a su estado de =C3=A1nimo se refiere, sin embargo esta semana hubo un hecho que marc=C3=B3 el curso de su esfera emocional y su vida. Falleci=C3=B3 su cu=C3=B1ado y durante todo el transcurso de la semana estuvo acompa==C3=B1ando y ayudando en aquello.Don Jose expresa que este desafortunado evento sin duda le afect=C3=B3 negativamente ya que el sent=C3=ADa un profundo aprecio por su cu=C3=B1ado. Sin embargoel paciente puede visualizar aspectos positivos de forma resiliente ante inminente evento, los cuales tienen que ver con  haberse encontrado con viejas amistades y poder compartir.Adem=C3=A1s, Don Jose pudo someterse al PET y la verdad es que los resultados lo dejaron un poco preocupado, ya que se muestran anomal=C3=ADas un poco extra=C3=B1as y que podr=C3=ADan tener directa relaci=C3=B3n con alg=C3=BAn  error en la aplicaci=C3=B3n del examen, detalle que no ha estado ajeno a los =C3=BAltimos ex=C3=A1menes de Don Jose.Por =C3=BAltimo, Don Jose asume que la muerte de su Cu=C3=B1ado tambi=C3=A9n le ayud=C3=B3 a poder quitarse una carga que ven=C3=ADa arrastrando hace tiempo, ya que la persona fallecida ya ahora est=C3=A1 descansando y pudo partir de la forma mas digna posible dentro de las circunstancias que se presentaban.El paciente considera que el parche transdermico que posee no cubre sus dolores de la forma que deber=C3=ADa, por lo que solicit=C3=B3 al medico la posibilidad de aumentar la dosis, pero por otro lado no presenta a priori una dependencia al parche ni al tratamiento.</div>
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Examen F=C3=ADsico<label for=3D"m_-8340138587390601059itemView.getDomIdToLabel()">
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*</span>
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</div>
</label>
<div class=3D"m_-8340138587390601059ss-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%">
Dentro de lo esperado. No ha perdido apetito, no hay nauseas, ni perdida de cabello.Destaca que los dolores en la parte baja de la espalda y los tobillos ya desaparecieron. No obstante el paciente presenta dolores a nivel muscular, los cuales lo mas probable sean producto del estr=C3=A9s al que ha estado sometido en esta semana en particular.</div>
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<div class=3D"m_-8340138587390601059ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_-8340138587390601059itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8340138587390601059ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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C=C3=A1ncer de pr=C3=B3stata</div>
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<br>
 <div class=3D"m_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-item-required m_-8340138587390601059ss-paragraph-text" style=3D"margin:12px 0">
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<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_1255665248">
<div class=3D"m_-8340138587390601059ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_-8340138587390601059itemView.getDomIdToLabel()">
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<span class=3D"m_-8340138587390601059ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8340138587390601059ss-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%">
Preparaci=C3=B3n para afrontar el proceso en funci=C3=B3n de visualizar todas las probabilidades en cuanto a que el paciente pueda colocarse en cada una de las posibilidades. Indagaci=C3==B3n respecto a la viabilidad de mantener el tratamiento o modificarlo en funci=C3=B3n de la dependencia y necesidad del paciente.</div>
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<div class=3D"m_-8340138587390601059ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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 <div class=3D"m_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-date" style=3D"margin:12px 0">
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Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
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<div class=3D"m_-8340138587390601059ss-q-date">
<div class=3D"m_-8340138587390601059ss-datetime-box m_-8340138587390601059goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
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Month</option>
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January</option>
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February</option>
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March</option>
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April</option>
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December</option>
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Day</option>
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7</option>
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8</option>
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15</option>
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20</option>
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21</option>
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22</option>
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25</option>
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26</option>
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27</option>
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28</option>
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31</option>
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1896</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1910</option>
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1911</option>
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1913</option>
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1914</option>
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1915</option>
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1918</option>
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1919</option>
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1920</option>
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1929</option>
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1930</option>
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1932</option>
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1933</option>
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1938</option>
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1939</option>
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1940</option>
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1943</option>
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1944</option>
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1946</option>
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1947</option>
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1951</option>
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1966</option>
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1967</option>
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1968</option>
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1972</option>
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1975</option>
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1976</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
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2019</option>
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2020</option>
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2021</option>
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2022</option>
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2023</option>
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2024</option>
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2025</option>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
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2032</option>
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2033</option>
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2034</option>
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2035</option>
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2036</option>
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2037</option>
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2038</option>
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2039</option>
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2040</option>
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2041</option>
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2042</option>
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2043</option>
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2044</option>
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2045</option>
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2046</option>
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2047</option>
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2048</option>
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2049</option>
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2050</option>
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2051</option>
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2052</option>
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2053</option>
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2054</option>
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2055</option>
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2056</option>
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2057</option>
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2058</option>
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2059</option>
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2060</option>
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2061</option>
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2062</option>
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2063</option>
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2064</option>
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2065</option>
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2066</option>
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2067</option>
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2068</option>
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2069</option>
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</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_74766472">
<div class=3D"m_-8340138587390601059ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_-8340138587390601059ss-q-help m_-8340138587390601059ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8340138587390601059ss-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 el monitoreo respecto a que el paciente pueda retomar sus acciones cotidianas de forma paulatina, adem=C3=A1s de indagar respecto a la posible modificaci=C3=B3n en la dosis y que impacto a nivel de dependencia tendr=C3=ADa este para con el paciente.</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8340138587390601059ss-form-question m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8340138587390601059ss-q-item-label" for=3D"m_-8340138587390601059entry_1219705969">
<div class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-q-help m_-8340138587390601059ss-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_-8340138587390601059ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-8340138587390601059ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-8340138587390601059ss-choice-item-control m_-8340138587390601059goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"ENFERMERA" id=3D"m_-8340138587390601059group_503039759_1" class=3D"m_-8340138587390601059ss-q-checkbox">
</span>
<span class=3D"m_-8340138587390601059ss-choice-label">
ENFERMERA</span>
</label>
</li>
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<label>
<span class=3D"m_-8340138587390601059ss-choice-item-control m_-8340138587390601059goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_-8340138587390601059group_503039759_2" class=3D"m_-8340138587390601059ss-q-checkbox">
</span>
<span class=3D"m_-8340138587390601059ss-choice-label">
TENS</span>
</label>
</li>
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<label>
<span class=3D"m_-8340138587390601059ss-choice-item-control m_-8340138587390601059goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id==3D"m_-8340138587390601059group_503039759_3" class=3D"m_-8340138587390601059ss-q-checkbox">
</span>
<span class=3D"m_-8340138587390601059ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
 <li class=3D"m_-8340138587390601059ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-8340138587390601059ss-choice-item-control m_-8340138587390601059goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"KINESIOLOGO" id=3D"m_-8340138587390601059group_503039759_4" class=3D"m_-8340138587390601059ss-q-checkbox">
</span>
<span class=3D"m_-8340138587390601059ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
 <li class=3D"m_-8340138587390601059ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-8340138587390601059ss-choice-item-control m_-8340138587390601059goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"PSICOLOGO" id=3D"m_-8340138587390601059group_503039759_5" class=3D"m_-8340138587390601059ss-q-checkbox">
</span>
<span class=3D"m_-8340138587390601059ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8340138587390601059errorbox-good">
<div dir=3D"auto" class=3D"m_-8340138587390601059ss-item m_-8340138587390601059ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-8340138587390601059ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8340138587390601059ss-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_-8340138587390601059ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
</form>
</div>
</div>
</td>
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<tr height=3D"24px">
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</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">
Create your own Google Form</a>
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<div id=3D"DAB4FAD8-2DD7-40BB-A1B8-4E2AA1F9FDF2">
<br>
 <table style=3D"border-top:1px solid #d3d4de">
	<tr>
      <td style=3D"width:55px;padding-top:18px">
<a href=3D"http://www.avg.com/email-signature?utm_medium=3Demail&amp;utm_source=3Dlink&amp;utm_campaign=3Dsig-email&amp;utm_content=3Dwebmail" target=3D"_blank">
<img src=3D"https://ipmcdn.avast.com/images/icons/icon-envelope-tick-green-avg-v1.png" alt==3D"" width=3D"46" height=3D"29" style=3D"width: 46px; height: 29px;">
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		<td style=3D"width:470px;padding-top:17px;color:#41424e;font-size:13px;font-family:Arial,Helvetica,sans-serif;line-height:18px">
Libre de virus. <a href=3D"http://www.avg.com/email-signature?utm_medium=3Demail&amp;utm_source=3Dlink&amp;utm_campaign=3Dsig-email&amp;utm_content=3Dwebmail" target=3D"_blank" style=3D"color:#4453ea">
www.avg.com</a>
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	</tr>
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<a href=3D"#DAB4FAD8-2DD7-40BB-A1B8-4E2AA1F9FDF2" width=3D"1" height=3D"1">
</a>
</div>
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