<HTML>
<BODY>
<div id="composeWebView_editable_content" data-mailruapp-compose-id="composeWebView_editable_content" style="text-align: left;">
<div>
Estimado junto con saludar, envío el informe correspondiente a la visita efectuada el día de hoy al paciente Julio Lagos de la ciudad de Chillán.&nbsp;</div>
<div>
<br>
</div>
<div>
Saludos</div>
<div>
<br>
</div>
<div id="mail-app-auto-signature">
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, 24 de mayo de 2019 21:23 -0400<br>
Asunto: Registro de Atención Domiciliaria Oncovida<br>
<br>
<br>
    <div id="composeWebView_previouse_content" data-mailruapp-compose-id="composeWebView_previouse_content">
<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;">
<div class="js-helper js-readmsg-msg">
	<style type="text/css">
</style>
 	<div>
		<base target="_self" href="https://e-aj.my.com/">
					<div id="style_15587473930000000016_BODY">
<div class="class_1558754975">
<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">
</td>
</tr>
</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">
<tbody>
<tr height="24px">
<td>
</td>
</tr>
<tr>
<td>
<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>
<td>
<div style="font-size: 13px;line-height: 18px;color: #424242;">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<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%;">
1864295-6</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%;">
Julio Lagos</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 en buen estado general, lucido, consciente y orientado en tiempo y espacio, se encuentra sin dolor al momento de la evaluación. Manifiesta que esta sin molestias, que no siente dolor y de buen ánimo.su alimentación es de forma normal y sin ayuda.sigue con nicturia, por lo cual su descanso se ve interrumpido constantemente,Presenta hematuria ocasional.  orina y defeca sin problemas. sin nauseas ni vómitos.Escala de Glasgow: 15 puntos.Escala de Norton: 19 puntos. Escala de Downton: 1 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 con ayuda ortopedica, lucido, orientado en tiempo y espacio, facie tranquila, constitución mesomorfa, piel y anexos normales. Al examen físico segmentario, sin hallazgos relevantes.Al control de signos vitales: paciente con presión optima de 118/72mmhg, normocárdico 61 lpm, afebril 36,5°C, y eupneico 12 rpm.</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 próstata</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;">
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%;">
Dieta rica en fibras.</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-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%;">
</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;">
 <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>
 <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.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_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>
 <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-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>
 <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 leyenda">
</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">
Crea tu propio formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
							<base target="_self" href="https://e-aj.my.com/">
	</div>
	</div>
</blockquote>
</div>
</div>
</BODY>
</HTML>
Cg==----ALT--Ms0SxO751558747736--