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Yanina Anziani Araya<div>
Enfermera&nbsp;</div>
</div>
<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: viernes, 10 de mayo de 2019 21:12 -0400<br>
Asunto: Registro de Atención Domiciliaria Oncovida<br>
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<table border="0" cellpadding="0" cellspacing="0" style="background-color:rgb(38,4,154);" width="100%" role="presentation">
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<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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<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 llenar <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>
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<div style="font-size: 13px;line-height: 18px;color: #424242;">
Estas son tus respuestas:</div>
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<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">
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<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 título">
</div>
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 <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>
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 <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 título">
</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%;">
7710512-3</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%;">
Juan Carrillo</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%;">
El Carmen</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 título">
</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_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_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_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 rango 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 rango 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 rango 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, lúcido, consciente, orientado en tiempo y espacio, con antecedentes mórbidos de HTA en TT°, a la evaluación con dolor moderado con EVA de 4 puntos.Manifiesta enojo y descontento por no contar con visita por parte del médico. Refiere que sufrió de una crisis de pánico, debido a la pérdida de su cabello producto de la quimioterapia Familiar refiere que el pcte aún se encuentra muy dependiente, para tomarse los medicamentos y alimentarse.   Paciente se alimenta de forma normal, con poca ingesta de agua, solicita contar con un profesional de nutrición, ya que refiere no saber qué comer.Aun sigue con los problemas de estreñimiento, ingiere la lactulosa, pero no todos los días, familiar refiere que le da a beber papa rallada con gotas de limón y un poco de aceite de oliva, en ayunas, sin hematuria.Sin vómitos ni nauseas.Paciente autovalente, logra satisfacer sus necesidades básicas.Escala de Glasgow: 15 puntos.Escala de Norton: 19 puntos. Escala de Dowton: 2 puntos.</div>
</div>
</div>
</div>
<br>
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<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, lúcido, orientado en tiempo y espacio.constitución mesomorfa, piel y anexos normales.al examen físico segmentario, alopecia areata, presenta CVC en tórax lado izquierdo, sin presencia de infección. sonda foley instalada el 11 de abril. signos vitales:normotenso 132/84 mmhg. normocardicado 85 lpm.eupneico 13 rpm.  afebril 36,5 °C.</div>
</div>
</div>
</div>
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<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;">
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<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 próstata</div>
</div>
</div>
</div>
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<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%;">
Aumentar ingesta de líquidos.Dieta rica en fibras.Control en una semana. </div>
</div>
</div>
</div>
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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%;">
Tralp 37,5mg. 1 comprimido cada 8 hora (S.O.S)Tamsulosina Clorhidrato 0,4 mg 1 cada 24 horas.Omeprazol 20 mg 1 comprimido cada 24 horas. Losartan 50 mg 1 comprimido cada 12 horas.Hidrocloratiasida 50 mg 1 comprimido cada 24 horas.Amlopidino 10 mg 1 comprimido cada 24 horas. </div>
</div>
</div>
</div>
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<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-date_mailru_css_attribute_postfix" style="margin:12px 0;">
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<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;">
 <select name="entry.2063615873_month" class="ss-month-dropdown_mailru_css_attribute_postfix" aria-label="Mes">
<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.2063615873_day" class="ss-day-dropdown_mailru_css_attribute_postfix" aria-label="Día del mes">
<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>
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9</option>
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10</option>
 <option value="11">
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>
 <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.2063615873_year" aria-label="Año">
<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>
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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>
 <option value="1911">
1911</option>
 <option value="1912">
1912</option>
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1913</option>
 <option value="1914">
1914</option>
 <option value="1915">
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>
 <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>
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1931</option>
 <option value="1932">
1932</option>
 <option value="1933">
1933</option>
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1934</option>
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1935</option>
 <option value="1936">
1936</option>
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1937</option>
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1938</option>
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1939</option>
 <option value="1940">
1940</option>
 <option value="1941">
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>
 <option value="1946">
1946</option>
 <option value="1947">
1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
 <option value="1955">
1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
 <option value="1962">
1962</option>
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1963</option>
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1964</option>
 <option value="1965">
1965</option>
 <option value="1966">
1966</option>
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1967</option>
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1968</option>
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1969</option>
 <option value="1970">
1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
 <option value="2009">
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>
 <option value="2015">
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>
 <option value="2039">
2039</option>
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2040</option>
 <option value="2041">
2041</option>
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2042</option>
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2043</option>
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2044</option>
 <option value="2045">
2045</option>
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2046</option>
 <option value="2047">
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>
 <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>
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<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>
 <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-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%;">
<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://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style="width: 78px;outline:none;" alt="Imagen sin título">
</div>
</div>
</div>
</div>
<br>
</form>
</div>
</div>
</td>
</tr>
<tr height="24px">
</tr>
</tbody>
</table>
</div>
<table align="center" cellpadding="0" cellspacing="0" style="max-width: 672px;min-width: 154px;" width="100%" role="presentation">
<tbody>
<tr height="24px">
<td>
</td>
</tr>
<tr>
<td>
<a href="https://docs.google.com/forms?usp=mail_form_link" style="color: #424242;font-size: 13px;" target="_blank" rel=" noopener noreferrer">
Crear tu propio Formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
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							<base target="_self" href="https://e-aj.my.com/">
	</div>
	</div>
</blockquote>
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