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Saludos&nbsp;</div>
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<div id="mail-app-auto-signature">
Yanina Anziani Araya<div>
Enfermera&nbsp;</div>
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<br>
<br>
-------- Mensaje reenviado --------<br>
De: Formularios de Google &lt;forms-receipts-noreply@google.com&gt;<br>
A: &lt;yaninaanziani@telemed-chile.cl&gt;<br>
Fecha: jueves, 18 de abril de 2019 23:39 -0400<br>
Asunto: Registro de Atención Domiciliaria Oncovida<br>
<br>
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<blockquote id="mail-app-auto-quote" style="border-left-width: 1px; border-left-style: solid; border-left-color: rgb(252, 44, 56); margin: 10px 0px 10px 5px; padding: 0px 0px 0px 10px; display: inherit;">
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<table border="0" cellpadding="0" cellspacing="0" style="background-color:rgb(38,4,154);" width="100%" role="presentation">
<tbody>
<tr height="64px">
<td style="padding-left: 24px">
<img alt="Formularios de Google" height="26px" style="display: inline-block;margin: 0;vertical-align: middle;" width="143px" src="https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
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</tbody>
</table>
<div style="padding: 24px;background-color:rgb(229,218,254)">
<div align="center" style="background-color: #fff;border-bottom: 1px solid #e0e0e0;margin: 0 auto;max-width: 624px;min-width: 154px;padding: 0 24px;">
<table align="center" cellpadding="0" cellspacing="0" style="background-color: #fff;" width="100%" role="presentation">
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<div style="font-size: 13px;line-height: 18px;color: #424242;font-weight: 700">
Gracias por rellenar <a href="https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=mail_form_link" target="_blank" rel=" noopener noreferrer">
Registro de Atención Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height="12px">
</tr>
<tr>
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<div style="font-size: 13px;line-height: 18px;color: #424242;">
Esto es lo que nos has enviado:</div>
</td>
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<tr>
<td>
<div class="ss-form-container_mailru_css_attribute_postfix">
<div class="ss-form-heading_mailru_css_attribute_postfix">
<h1 class="ss-form-title_mailru_css_attribute_postfix" dir="ltr" style="margin:.67em 0;">
Registro de Atención Domiciliaria Oncovida</h1>
<div class="ss-form-desc_mailru_css_attribute_postfix ss-no-ignore-whitespace_mailru_css_attribute_postfix" style="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 continuación indique su correo electrónico.</div>
</div>
<div class="ss-form_mailru_css_attribute_postfix">
<form id="ss-form_mailru_css_attribute_postfix" target="_blank" action="#" method="POST" onsubmit="return false" rel=" noopener noreferrer">
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Dirección de correo electrónico<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-text_mailru_css_attribute_postfix ss-printable-text-line_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
<a href="mailto:yaninaanziani@telemed-chile.cl">
yaninaanziani@telemed-chile.cl</a>
</div>
</div>
</div>
</div>
<div class="errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-embeddable-object-container_mailru_css_attribute_postfix" style="margin:12px 0;max-width:100%;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
</h2>
<div style="text-align: right;">
<img class="ss-image_mailru_css_attribute_postfix" title="" src="https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style="width: 78px;outline:none;" alt="Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class="errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-page-break_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class="ss-page-title_mailru_css_attribute_postfix" style="padding:0.4em;background-color:#eee;">
Identificación del Prestador</h2>
<div class="ss-page-description_mailru_css_attribute_postfix ss-no-ignore-whitespace_mailru_css_attribute_postfix" dir="auto" style="white-space:pre-wrap;word-wrap:break-word;">
Aquí debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Primer Nombre y Apellido Paterno<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Yanina Anziani </div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
RUT<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
17843016-5</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-select_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Tipo<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
Si asisten más de 1 prestador simultáneamente, cada uno debe hacer un registro independiente</div>
<select name="entry.133691676" id="entry_133691676_mailru_css_attribute_postfix" aria-label="Tipo Si asisten más de 1 prestador simultáneamente, cada uno debe hacer un registro independiente" aria-required="true">
<option value="">
</option>
<option value="MEDICO">
MEDICO</option>
 <option value="ENFERMERA/O">
ENFERMERA/O</option>
 <option value="TENS">
TENS</option>
 <option value="KINESIOLOGA/O">
KINESIOLOGA/O</option>
 <option value="PSICOLOGO">
PSICOLOGO</option>
 <option value="NUTRICIONISTA">
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class="errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-embeddable-object-container_mailru_css_attribute_postfix" style="margin:12px 0;max-width:100%;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
</h2>
<div style="text-align: right;">
<img class="ss-image_mailru_css_attribute_postfix" title="" src="https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style="width: 78px;outline:none;" alt="Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class="errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-page-break_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class="ss-page-title_mailru_css_attribute_postfix" style="padding:0.4em;background-color:#eee;">
Identificación del Paciente</h2>
<div class="ss-page-description_mailru_css_attribute_postfix ss-no-ignore-whitespace_mailru_css_attribute_postfix" dir="auto" style="white-space:pre-wrap;word-wrap:break-word;">
En esta sección debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
 <div class="errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-section-header_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class="ss-section-title_mailru_css_attribute_postfix" style="background-color:#eee;padding:0.4em;">
Datos Personales del Paciente</h2>
<div class="ss-section-description_mailru_css_attribute_postfix ss-no-ignore-whitespace_mailru_css_attribute_postfix" style="margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word;">
</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Ingrese el Rut del Paciente<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
4988089-5</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Ingrese el Primer Nombre y Apellido Paterno del Paciente<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Nain Dagach</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-select_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Previsión<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<select name="entry.545002227" id="entry_545002227_mailru_css_attribute_postfix" aria-label="Previsión" aria-required="true">
<option value="">
</option>
<option value="BANMEDICA">
BANMEDICA</option>
 <option value="CAPREDENA">
CAPREDENA</option>
 <option value="COLMENA">
COLMENA</option>
 <option value="CONSALUD">
CONSALUD</option>
 <option value="CRUZ BLANCA">
CRUZ BLANCA</option>
 <option value="DIPRECA">
DIPRECA</option>
 <option value="FONASA">
FONASA</option>
 <option value="FUNDACION">
FUNDACION</option>
 <option value="ISAPRES DEL COBRE">
ISAPRES DEL COBRE</option>
 <option value="NUEVA MASVIDA">
NUEVA MASVIDA</option>
 <option value="VIDATRES">
VIDATRES</option>
 <option value="PARTICULAR">
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Ciudad<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Chillán </div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Comuna<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Chillán</div>
</div>
</div>
</div>
<br>
 <div class="errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-embeddable-object-container_mailru_css_attribute_postfix" style="margin:12px 0;max-width:100%;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
</h2>
<div style="text-align: right;">
<img class="ss-image_mailru_css_attribute_postfix" title="" src="https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style="width: 78px;outline:none;" alt="Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class="errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-page-break_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class="ss-page-title_mailru_css_attribute_postfix" style="padding:0.4em;background-color:#eee;">
Registro de la Atención Domiciliaria</h2>
<div class="ss-page-description_mailru_css_attribute_postfix ss-no-ignore-whitespace_mailru_css_attribute_postfix" dir="auto" style="white-space:pre-wrap;word-wrap:break-word;">
En esta sección debe ingresar los datos de la atención domiciliaria</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-radio_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Tipo de Atención<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<ul class="ss-choices_mailru_css_attribute_postfix" role="radiogroup" aria-label="Tipo de Atención" style="list-style:none;padding:0;margin:.5em 0 0;">
<li class="ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em;">
<span class="ss-choice-item-control_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block;">
<input type="radio" name="entry.1222378237" value="Domicilio" id="group_1222378237_1_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="Domicilio" aria-required="true">
</span>
<span class="ss-choice-label_mailru_css_attribute_postfix">
Domicilio</span>
</li>
 <li class="ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em;">
<span class="ss-choice-item-control_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block;">
<input type="radio" name="entry.1222378237" value="Ambulatorio" id="group_1222378237_2_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="Ambulatorio" aria-required="true">
</span>
<span class="ss-choice-label_mailru_css_attribute_postfix">
Ambulatorio</span>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-date_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Fecha de la Atención<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<div class="ss-q-date_mailru_css_attribute_postfix" role="group" aria-label="Fecha de la Atención">
<div class="ss-datetime-box_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" role="group" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block;">
 <select name="entry.1705849412_day" class="ss-day-dropdown_mailru_css_attribute_postfix" aria-label="Día del mes" aria-required="true">
<option value="">
Día</option>
<option value="1">
1</option>
 <option value="2">
2</option>
 <option value="3">
3</option>
 <option value="4">
4</option>
 <option value="5">
5</option>
 <option value="6">
6</option>
 <option value="7">
7</option>
 <option value="8">
8</option>
 <option value="9">
9</option>
 <option value="10">
10</option>
 <option value="11">
11</option>
 <option value="12">
12</option>
 <option value="13">
13</option>
 <option value="14">
14</option>
 <option value="15">
15</option>
 <option value="16">
16</option>
 <option value="17">
17</option>
 <option value="18">
18</option>
 <option value="19">
19</option>
 <option value="20">
20</option>
 <option value="21">
21</option>
 <option value="22">
22</option>
 <option value="23">
23</option>
 <option value="24">
24</option>
 <option value="25">
25</option>
 <option value="26">
26</option>
 <option value="27">
27</option>
 <option value="28">
28</option>
 <option value="29">
29</option>
 <option value="30">
30</option>
 <option value="31">
31</option>
</select>
   <select name="entry.1705849412_month" class="ss-month-dropdown_mailru_css_attribute_postfix" aria-label="Mes" aria-required="true">
<option value="">
Mes</option>
<option value="1">
enero</option>
 <option value="2">
febrero</option>
 <option value="3">
marzo</option>
 <option value="4">
abril</option>
 <option value="5">
mayo</option>
 <option value="6">
junio</option>
 <option value="7">
julio</option>
 <option value="8">
agosto</option>
 <option value="9">
septiembre</option>
 <option value="10">
octubre</option>
 <option value="11">
noviembre</option>
 <option value="12">
diciembre</option>
</select>
 <select name="entry.1705849412_year" aria-label="Año" aria-required="true">
<option value="">
Año</option>
<option value="1896">
1896</option>
 <option value="1897">
1897</option>
 <option value="1898">
1898</option>
 <option value="1899">
1899</option>
 <option value="1900">
1900</option>
 <option value="1901">
1901</option>
 <option value="1902">
1902</option>
 <option value="1903">
1903</option>
 <option value="1904">
1904</option>
 <option value="1905">
1905</option>
 <option value="1906">
1906</option>
 <option value="1907">
1907</option>
 <option value="1908">
1908</option>
 <option value="1909">
1909</option>
 <option value="1910">
1910</option>
 <option value="1911">
1911</option>
 <option value="1912">
1912</option>
 <option value="1913">
1913</option>
 <option value="1914">
1914</option>
 <option value="1915">
1915</option>
 <option value="1916">
1916</option>
 <option value="1917">
1917</option>
 <option value="1918">
1918</option>
 <option value="1919">
1919</option>
 <option value="1920">
1920</option>
 <option value="1921">
1921</option>
 <option value="1922">
1922</option>
 <option value="1923">
1923</option>
 <option value="1924">
1924</option>
 <option value="1925">
1925</option>
 <option value="1926">
1926</option>
 <option value="1927">
1927</option>
 <option value="1928">
1928</option>
 <option value="1929">
1929</option>
 <option value="1930">
1930</option>
 <option value="1931">
1931</option>
 <option value="1932">
1932</option>
 <option value="1933">
1933</option>
 <option value="1934">
1934</option>
 <option value="1935">
1935</option>
 <option value="1936">
1936</option>
 <option value="1937">
1937</option>
 <option value="1938">
1938</option>
 <option value="1939">
1939</option>
 <option value="1940">
1940</option>
 <option value="1941">
1941</option>
 <option value="1942">
1942</option>
 <option value="1943">
1943</option>
 <option value="1944">
1944</option>
 <option value="1945">
1945</option>
 <option value="1946">
1946</option>
 <option value="1947">
1947</option>
 <option value="1948">
1948</option>
 <option value="1949">
1949</option>
 <option value="1950">
1950</option>
 <option value="1951">
1951</option>
 <option value="1952">
1952</option>
 <option value="1953">
1953</option>
 <option value="1954">
1954</option>
 <option value="1955">
1955</option>
 <option value="1956">
1956</option>
 <option value="1957">
1957</option>
 <option value="1958">
1958</option>
 <option value="1959">
1959</option>
 <option value="1960">
1960</option>
 <option value="1961">
1961</option>
 <option value="1962">
1962</option>
 <option value="1963">
1963</option>
 <option value="1964">
1964</option>
 <option value="1965">
1965</option>
 <option value="1966">
1966</option>
 <option value="1967">
1967</option>
 <option value="1968">
1968</option>
 <option value="1969">
1969</option>
 <option value="1970">
1970</option>
 <option value="1971">
1971</option>
 <option value="1972">
1972</option>
 <option value="1973">
1973</option>
 <option value="1974">
1974</option>
 <option value="1975">
1975</option>
 <option value="1976">
1976</option>
 <option value="1977">
1977</option>
 <option value="1978">
1978</option>
 <option value="1979">
1979</option>
 <option value="1980">
1980</option>
 <option value="1981">
1981</option>
 <option value="1982">
1982</option>
 <option value="1983">
1983</option>
 <option value="1984">
1984</option>
 <option value="1985">
1985</option>
 <option value="1986">
1986</option>
 <option value="1987">
1987</option>
 <option value="1988">
1988</option>
 <option value="1989">
1989</option>
 <option value="1990">
1990</option>
 <option value="1991">
1991</option>
 <option value="1992">
1992</option>
 <option value="1993">
1993</option>
 <option value="1994">
1994</option>
 <option value="1995">
1995</option>
 <option value="1996">
1996</option>
 <option value="1997">
1997</option>
 <option value="1998">
1998</option>
 <option value="1999">
1999</option>
 <option value="2000">
2000</option>
 <option value="2001">
2001</option>
 <option value="2002">
2002</option>
 <option value="2003">
2003</option>
 <option value="2004">
2004</option>
 <option value="2005">
2005</option>
 <option value="2006">
2006</option>
 <option value="2007">
2007</option>
 <option value="2008">
2008</option>
 <option value="2009">
2009</option>
 <option value="2010">
2010</option>
 <option value="2011">
2011</option>
 <option value="2012">
2012</option>
 <option value="2013">
2013</option>
 <option value="2014">
2014</option>
 <option value="2015">
2015</option>
 <option value="2016">
2016</option>
 <option value="2017">
2017</option>
 <option value="2018">
2018</option>
 <option value="2019">
2019</option>
 <option value="2020">
2020</option>
 <option value="2021">
2021</option>
 <option value="2022">
2022</option>
 <option value="2023">
2023</option>
 <option value="2024">
2024</option>
 <option value="2025">
2025</option>
 <option value="2026">
2026</option>
 <option value="2027">
2027</option>
 <option value="2028">
2028</option>
 <option value="2029">
2029</option>
 <option value="2030">
2030</option>
 <option value="2031">
2031</option>
 <option value="2032">
2032</option>
 <option value="2033">
2033</option>
 <option value="2034">
2034</option>
 <option value="2035">
2035</option>
 <option value="2036">
2036</option>
 <option value="2037">
2037</option>
 <option value="2038">
2038</option>
 <option value="2039">
2039</option>
 <option value="2040">
2040</option>
 <option value="2041">
2041</option>
 <option value="2042">
2042</option>
 <option value="2043">
2043</option>
 <option value="2044">
2044</option>
 <option value="2045">
2045</option>
 <option value="2046">
2046</option>
 <option value="2047">
2047</option>
 <option value="2048">
2048</option>
 <option value="2049">
2049</option>
 <option value="2050">
2050</option>
 <option value="2051">
2051</option>
 <option value="2052">
2052</option>
 <option value="2053">
2053</option>
 <option value="2054">
2054</option>
 <option value="2055">
2055</option>
 <option value="2056">
2056</option>
 <option value="2057">
2057</option>
 <option value="2058">
2058</option>
 <option value="2059">
2059</option>
 <option value="2060">
2060</option>
 <option value="2061">
2061</option>
 <option value="2062">
2062</option>
 <option value="2063">
2063</option>
 <option value="2064">
2064</option>
 <option value="2065">
2065</option>
 <option value="2066">
2066</option>
 <option value="2067">
2067</option>
 <option value="2068">
2068</option>
 <option value="2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-time_mailru_css_attribute_postfix" style="margin:12px 0;font:inherit;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Hora de la Atención<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<div class="ss-q-time_mailru_css_attribute_postfix">
<div class="ss-datetime-box_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" dir="ltr" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block;">
<select name="entry.206244955_hour" aria-label="Hora" aria-required="true">
<option value="">
h</option>
<option value="00">
00</option>
 <option value="01">
01</option>
 <option value="02">
02</option>
 <option value="03">
03</option>
 <option value="04">
04</option>
 <option value="05">
05</option>
 <option value="06">
06</option>
 <option value="07">
07</option>
 <option value="08">
08</option>
 <option value="09">
09</option>
 <option value="10">
10</option>
 <option value="11">
11</option>
 <option value="12">
12</option>
 <option value="13">
13</option>
 <option value="14">
14</option>
 <option value="15">
15</option>
 <option value="16">
16</option>
 <option value="17">
17</option>
 <option value="18">
18</option>
 <option value="19">
19</option>
 <option value="20">
20</option>
 <option value="21">
21</option>
 <option value="22">
22</option>
 <option value="23">
23</option>
</select>
:<select name="entry.206244955_minute" aria-label="Minuto" aria-required="true">
<option value="">
min</option>
<option value="00">
00</option>
 <option value="01">
01</option>
 <option value="02">
02</option>
 <option value="03">
03</option>
 <option value="04">
04</option>
 <option value="05">
05</option>
 <option value="06">
06</option>
 <option value="07">
07</option>
 <option value="08">
08</option>
 <option value="09">
09</option>
 <option value="10">
10</option>
 <option value="11">
11</option>
 <option value="12">
12</option>
 <option value="13">
13</option>
 <option value="14">
14</option>
 <option value="15">
15</option>
 <option value="16">
16</option>
 <option value="17">
17</option>
 <option value="18">
18</option>
 <option value="19">
19</option>
 <option value="20">
20</option>
 <option value="21">
21</option>
 <option value="22">
22</option>
 <option value="23">
23</option>
 <option value="24">
24</option>
 <option value="25">
25</option>
 <option value="26">
26</option>
 <option value="27">
27</option>
 <option value="28">
28</option>
 <option value="29">
29</option>
 <option value="30">
30</option>
 <option value="31">
31</option>
 <option value="32">
32</option>
 <option value="33">
33</option>
 <option value="34">
34</option>
 <option value="35">
35</option>
 <option value="36">
36</option>
 <option value="37">
37</option>
 <option value="38">
38</option>
 <option value="39">
39</option>
 <option value="40">
40</option>
 <option value="41">
41</option>
 <option value="42">
42</option>
 <option value="43">
43</option>
 <option value="44">
44</option>
 <option value="45">
45</option>
 <option value="46">
46</option>
 <option value="47">
47</option>
 <option value="48">
48</option>
 <option value="49">
49</option>
 <option value="50">
50</option>
 <option value="51">
51</option>
 <option value="52">
52</option>
 <option value="53">
53</option>
 <option value="54">
54</option>
 <option value="55">
55</option>
 <option value="56">
56</option>
 <option value="57">
57</option>
 <option value="58">
58</option>
 <option value="59">
59</option>
</select>
<div class="ss-datetime-box-spacer_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" style="height:32px;vertical-align:middle;display:inline-block;">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-select_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Performance Status ECOG del Paciente<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<select name="entry.1747608258" id="entry_1747608258_mailru_css_attribute_postfix" aria-label="Performance Status ECOG del Paciente" aria-required="true">
<option value="">
</option>
<option value="0">
0</option>
 <option value="1">
1</option>
 <option value="2">
2</option>
 <option value="3">
3</option>
 <option value="4">
4</option>
</select>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-scale_mailru_css_attribute_postfix" style="margin:12px 0;overflow-x:auto;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Escala Dolor EVA Actual</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<table border="0" cellpadding="5" cellspacing="0" id="entry_1421689035_mailru_css_attribute_postfix">
<tbody>
<tr aria-hidden="true">
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
0</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
1</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
2</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
3</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
4</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
5</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
6</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
7</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
8</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
9</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
10</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
</td>
</tr>
<tr role="radiogroup" aria-label="Escala Dolor EVA Actual  Selecciona un valor en el intervalo de 0 a 10 .">
<td class="ss-scalerow_mailru_css_attribute_postfix ss-leftlabel_mailru_css_attribute_postfix" style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0;">
<div aria-hidden="true" class="aria-todo_mailru_css_attribute_postfix">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="0" id="group_1421689035_1_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="0">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="1" id="group_1421689035_2_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="1">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="2" id="group_1421689035_3_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="2">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="3" id="group_1421689035_4_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="3">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="4" id="group_1421689035_5_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="4">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="5" id="group_1421689035_6_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="5">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="6" id="group_1421689035_7_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="6">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="7" id="group_1421689035_8_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="7">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="8" id="group_1421689035_9_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="8">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="9" id="group_1421689035_10_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="9">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="10" id="group_1421689035_11_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="10">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix ss-rightlabel_mailru_css_attribute_postfix" aria-hidden="true" style="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="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-scale_mailru_css_attribute_postfix" style="margin:12px 0;overflow-x:auto;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Escala Dolor EVA Máximo</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<table border="0" cellpadding="5" cellspacing="0" id="entry_1244707512_mailru_css_attribute_postfix">
<tbody>
<tr aria-hidden="true">
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
0</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
1</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
2</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
3</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
4</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
5</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
6</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
7</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
8</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
9</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
10</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
</td>
</tr>
<tr role="radiogroup" aria-label="Escala Dolor EVA Máximo  Selecciona un valor en el intervalo de 0 a 10 .">
<td class="ss-scalerow_mailru_css_attribute_postfix ss-leftlabel_mailru_css_attribute_postfix" style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0;">
<div aria-hidden="true" class="aria-todo_mailru_css_attribute_postfix">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="0" id="group_1244707512_1_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="0">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="1" id="group_1244707512_2_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="1">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="2" id="group_1244707512_3_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="2">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="3" id="group_1244707512_4_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="3">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="4" id="group_1244707512_5_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="4">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="5" id="group_1244707512_6_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="5">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="6" id="group_1244707512_7_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="6">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="7" id="group_1244707512_8_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="7">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="8" id="group_1244707512_9_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="8">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="9" id="group_1244707512_10_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="9">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="10" id="group_1244707512_11_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="10">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix ss-rightlabel_mailru_css_attribute_postfix" aria-hidden="true" style="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="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-scale_mailru_css_attribute_postfix" style="margin:12px 0;overflow-x:auto;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Escala Dolor EVA Mínimo</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<table border="0" cellpadding="5" cellspacing="0" id="entry_853118630_mailru_css_attribute_postfix">
<tbody>
<tr aria-hidden="true">
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
0</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
1</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
2</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
3</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
4</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
5</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
6</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
7</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
8</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
9</td>
 <td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
10</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center;">
</td>
</tr>
<tr role="radiogroup" aria-label="Escala Dolor EVA Mínimo  Selecciona un valor en el intervalo de 0 a 10 .">
<td class="ss-scalerow_mailru_css_attribute_postfix ss-leftlabel_mailru_css_attribute_postfix" style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0;">
<div aria-hidden="true" class="aria-todo_mailru_css_attribute_postfix">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="0" id="group_853118630_1_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="0">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="1" id="group_853118630_2_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="1">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="2" id="group_853118630_3_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="2">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="3" id="group_853118630_4_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="3">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="4" id="group_853118630_5_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="4">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="5" id="group_853118630_6_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="5">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="6" id="group_853118630_7_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="6">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="7" id="group_853118630_8_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="7">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="8" id="group_853118630_9_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="8">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="9" id="group_853118630_10_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="9">
</div>
</td>
 <td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="10" id="group_853118630_11_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="10">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix ss-rightlabel_mailru_css_attribute_postfix" aria-hidden="true" style="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="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-paragraph-text_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Anamnesis/Evolución<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Paciente hemodinámicamente estable, en buenas condiciones generales, consciente, orientado en tiempo y espacio, a la evaluación se encuentra sin dolor, poco colaborador, no refiere molestias.Al momento de la visita el usuario se encontraba sin el familiar cuidador, solo con la persona que trabaja en su hogar, ella refiere que paciente se encuentra excelentes condiciones físicas, indica que quiere permanecer acostado todo el día.Cuidadora refiere que tiende a "pegarse" con diversos temas. Paciente con pensamiento perseverante.  Paciente se alimenta de forma normal, refiere poca ingesta de líquidos. Sin problemas para orinar ni defecar.Sin vómitos y nauseas.Paciente autovalente, puede satisfacer sus necesidades básicas solo. Escala de Glasgow: 15 puntos.Escala de Norton: 19 puntos.Escala de Downton: 3 puntos.</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-paragraph-text_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Examen Físico<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Paciente deambula de forma normal, facie tranquila, consiente, orientado en tiempo y espacio, constitución mesomorfa, piel hidratada.Al examen segmentario sin hallazgos sobresalientes. Al control de signos vitales:Eupneico 14 rpm.Normocardico 71 lpm.Afebril 36.6 °C.Normotenso 122/80 mmhg.   </div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Diagnóstico<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
CA prostata </div>
</div>
</div>
</div>
<br>
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<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-paragraph-text_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Plan de Tratamiento e Indicaciones<span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Caminata diaria a tolerancia. Aumento de ingesta de líquidos.</div>
</div>
</div>
</div>
<br>
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<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-paragraph-text_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Medicamentos Indicados</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Decapeptyl 11,25 mg trimestral ultima administración con fecha de 15 de marzo 2019.</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-date_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Fecha aproximada del Próximo Control con usted</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<div class="ss-q-date_mailru_css_attribute_postfix" role="group" aria-label="Fecha aproximada del Próximo Control con usted">
<div class="ss-datetime-box_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" role="group" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block;">
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<option value="">
Día</option>
<option value="1">
1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
 <option value="28">
28</option>
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29</option>
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30</option>
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31</option>
</select>
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<option value="">
Mes</option>
<option value="1">
enero</option>
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febrero</option>
 <option value="3">
marzo</option>
 <option value="4">
abril</option>
 <option value="5">
mayo</option>
 <option value="6">
junio</option>
 <option value="7">
julio</option>
 <option value="8">
agosto</option>
 <option value="9">
septiembre</option>
 <option value="10">
octubre</option>
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noviembre</option>
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diciembre</option>
</select>
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<option value="">
Año</option>
<option value="1896">
1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1953</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2014</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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2024</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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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>
 <option value="2068">
2068</option>
 <option value="2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Tratamiento Realizado (si corresponde)</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
</div>
</div>
</div>
</div>
<br>
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<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-checkbox_mailru_css_attribute_postfix" style="margin:12px 0;">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Derivación a otro Prestador Domiciliario</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
Sólo llene esta sección si es médico y solicita la visita de otro prestador del equipo</div>
<ul class="ss-choices_mailru_css_attribute_postfix" role="group" aria-label="Derivación a otro Prestador Domiciliario Sólo llene esta sección si es médico y solicita la visita de otro prestador del equipo" style="list-style:none;padding:0;margin:.5em 0 0;">
<li class="ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em;">
<span class="ss-choice-item-control_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block;">
<input type="checkbox" name="entry.503039759" value="ENFERMERA" id="group_503039759_1_mailru_css_attribute_postfix" role="checkbox" class="ss-q-checkbox_mailru_css_attribute_postfix">
</span>
<span class="ss-choice-label_mailru_css_attribute_postfix">
ENFERMERA</span>
</li>
 <li class="ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em;">
<span class="ss-choice-item-control_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block;">
<input type="checkbox" name="entry.503039759" value="TENS" id="group_503039759_2_mailru_css_attribute_postfix" role="checkbox" class="ss-q-checkbox_mailru_css_attribute_postfix">
</span>
<span class="ss-choice-label_mailru_css_attribute_postfix">
TENS</span>
</li>
 <li class="ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em;">
<span class="ss-choice-item-control_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block;">
<input type="checkbox" name="entry.503039759" value="NUTRICIONISTA" id="group_503039759_3_mailru_css_attribute_postfix" role="checkbox" class="ss-q-checkbox_mailru_css_attribute_postfix">
</span>
<span class="ss-choice-label_mailru_css_attribute_postfix">
NUTRICIONISTA</span>
</li>
 <li class="ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em;">
<span class="ss-choice-item-control_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block;">
<input type="checkbox" name="entry.503039759" value="KINESIOLOGO" id="group_503039759_4_mailru_css_attribute_postfix" role="checkbox" class="ss-q-checkbox_mailru_css_attribute_postfix">
</span>
<span class="ss-choice-label_mailru_css_attribute_postfix">
KINESIOLOGO</span>
</li>
 <li class="ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em;">
<span class="ss-choice-item-control_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block;">
<input type="checkbox" name="entry.503039759" value="PSICOLOGO" id="group_503039759_5_mailru_css_attribute_postfix" role="checkbox" class="ss-q-checkbox_mailru_css_attribute_postfix">
</span>
<span class="ss-choice-label_mailru_css_attribute_postfix">
PSICOLOGO</span>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class="errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-embeddable-object-container_mailru_css_attribute_postfix" style="margin:12px 0;max-width:100%;">
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<h2 class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
</h2>
<div style="text-align: right;">
<img class="ss-image_mailru_css_attribute_postfix" title="" src="https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style="width: 78px;outline:none;" alt="Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
</form>
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</td>
</tr>
<tr height="24px">
</tr>
</tbody>
</table>
</div>
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<a href="https://docs.google.com/forms?usp=mail_form_link" style="color: #424242;font-size: 13px;" target="_blank" rel=" noopener noreferrer">
Crea tu propio formulario de Google</a>
</td>
</tr>
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</table>
</div>
</div>
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							<base target="_self" href="https://e-aj.my.com/">
	</div>
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</blockquote>
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