<div dir=3D"ltr">
<br>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class==3D"gmail_attr">
---------- Forwarded message ---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Formularios de Google</strong>
 <span dir=3D"auto">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: mi=C3=A9., 17 jul. 2019 a las 15:50<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:elizabethcorreadiaz@gmail.com">
elizabethcorreadiaz@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Formularios de Google" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por rellenar <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp==3Dmail_form_link" target=3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_2224155344718066861ss-form-container">
<div class=3D"m_2224155344718066861ss-form-heading">
<h1 class=3D"m_2224155344718066861ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_2224155344718066861ss-form-desc m_2224155344718066861ss-no-ignore-whitespace" style=3D"font:inherit;width:99%;margin:0 0 1em;white-space:pre-wrap;word-wrap:break-word">
Este es el sistema de registro de atenciones domiciliarias de Oncovida.   Debe ser llenado por el prestador individual, y debe realizarse un registro por cada visita domiciliaria.   Si usted no es prestador de Oncovida por favor no llene este formulario.   A continuaci=C3=B3n indique su correo electr=C3=B3nico.</div>
</div>
<div class=3D"m_2224155344718066861ss-form">
<form method=3D"GET" id=3D"m_2224155344718066861ss-form" target=3D"_blank">
<br>
<div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-text" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861emailAddress">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Direcci=C3==B3n de correo electr=C3=B3nico<label for=3D"m_2224155344718066861emailAddress">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_2224155344718066861ss-q-text m_2224155344718066861ss-printable-text-line" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
<a href=3D"mailto:elizabethcorreadiaz@gmail.com" target=3D"_blank">
elizabethcorreadiaz@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_2224155344718066861ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2224155344718066861ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_2224155344718066861ss-page-description m_2224155344718066861ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
Aqu=C3=AD debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-text" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_579114469">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_2224155344718066861itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2224155344718066861ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
ELIZABETH CORREA</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-text" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_1276273985">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_2224155344718066861itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_2224155344718066861ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
16203285-2</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-select" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_133691676">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_2224155344718066861itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
Si asisten m=C3=A1s de 1 prestador simult=C3=A1neamente, cada uno debe hacer un registro independiente</div>
</label>
<select name=3D"entry.133691676" disabled id=3D"m_2224155344718066861entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled selected>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_2224155344718066861ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2224155344718066861ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_2224155344718066861ss-page-description m_2224155344718066861ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2224155344718066861ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_2224155344718066861ss-section-description m_2224155344718066861ss-no-ignore-whitespace" style=3D"margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-text" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_823811303">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_2224155344718066861itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_2224155344718066861ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
3437560-7</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-text" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_1959365839">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente<label for=3D"m_2224155344718066861itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2224155344718066861ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
MARIA ARANEDA</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-select" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_545002227">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_2224155344718066861itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.545002227" disabled id=3D"m_2224155344718066861entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled selected>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled>
COLMENA</option>
 <option value=3D"CONSALUD" disabled>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled>
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled>
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-text" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_1900161356">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_2224155344718066861itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2224155344718066861ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
VI=C3=91A DEL MAR</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-text" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_1298871758">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_2224155344718066861itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2224155344718066861ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
VI=C3=91A DEL MAR</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_2224155344718066861ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2224155344718066861ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_2224155344718066861ss-page-description m_2224155344718066861ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos de la atenci==C3=B3n domiciliaria</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-radio" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_2073233714">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_2224155344718066861itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_2224155344718066861ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_2224155344718066861ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2224155344718066861ss-choice-item-control m_2224155344718066861goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_2224155344718066861group_1222378237_1" class=3D"m_2224155344718066861ss-q-radio">
</span>
<span class=3D"m_2224155344718066861ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_2224155344718066861ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2224155344718066861ss-choice-item-control m_2224155344718066861goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_2224155344718066861group_1222378237_2" class=3D"m_2224155344718066861ss-q-radio">
</span>
<span class=3D"m_2224155344718066861ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-date" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_1705849412">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha de la Atenci=C3=B3n<label for=3D"m_2224155344718066861itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2224155344718066861ss-q-date">
<div class=3D"m_2224155344718066861ss-datetime-box m_2224155344718066861goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name=3D"entry.1705849412_day" disabled class=3D"m_2224155344718066861ss-day-dropdown" id=3D"m_2224155344718066861entry.1705849412_day">
<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
 <option value=3D"2">
2</option>
 <option value=3D"3">
3</option>
 <option value=3D"4">
4</option>
 <option value=3D"5">
5</option>
 <option value=3D"6">
6</option>
 <option value=3D"7">
7</option>
 <option value=3D"8">
8</option>
 <option value=3D"9">
9</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16" selected>
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value==3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
</select>
   <select name=3D"entry.1705849412_month" disabled class=3D"m_2224155344718066861ss-month-dropdown" id=3D"m_2224155344718066861entry.1705849412_month">
<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
 <option value=3D"2">
febrero</option>
 <option value=3D"3">
marzo</option>
 <option value=3D"4">
abril</option>
 <option value=3D"5">
mayo</option>
 <option value=3D"6">
junio</option>
 <option value==3D"7" selected>
julio</option>
 <option value=3D"8">
agosto</option>
 <option value=3D"9">
septiembre</option>
 <option value=3D"10">
octubre</option>
 <option value=3D"11">
noviembre</option>
 <option value=3D"12">
diciembre</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_2224155344718066861entry.1705849412_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
 <option value=3D"1898">
1898</option>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
1901</option>
 <option value=3D"1902">
1902</option>
 <option value=3D"1903">
1903</option>
 <option value=3D"1904">
1904</option>
 <option value=3D"1905">
1905</option>
 <option value=3D"1906">
1906</option>
 <option value=3D"1907">
1907</option>
 <option value=3D"1908">
1908</option>
 <option value=3D"1909">
1909</option>
 <option value=3D"1910">
1910</option>
 <option value=3D"1911">
1911</option>
 <option value=3D"1912">
1912</option>
 <option value=3D"1913">
1913</option>
 <option value=3D"1914">
1914</option>
 <option value=3D"1915">
1915</option>
 <option value=3D"1916">
1916</option>
 <option value=3D"1917">
1917</option>
 <option value=3D"1918">
1918</option>
 <option value=3D"1919">
1919</option>
 <option value=3D"1920">
1920</option>
 <option value=3D"1921">
1921</option>
 <option value=3D"1922">
1922</option>
 <option value=3D"1923">
1923</option>
 <option value==3D"1924">
1924</option>
 <option value=3D"1925">
1925</option>
 <option value==3D"1926">
1926</option>
 <option value=3D"1927">
1927</option>
 <option value==3D"1928">
1928</option>
 <option value=3D"1929">
1929</option>
 <option value==3D"1930">
1930</option>
 <option value=3D"1931">
1931</option>
 <option value==3D"1932">
1932</option>
 <option value=3D"1933">
1933</option>
 <option value==3D"1934">
1934</option>
 <option value=3D"1935">
1935</option>
 <option value==3D"1936">
1936</option>
 <option value=3D"1937">
1937</option>
 <option value==3D"1938">
1938</option>
 <option value=3D"1939">
1939</option>
 <option value==3D"1940">
1940</option>
 <option value=3D"1941">
1941</option>
 <option value==3D"1942">
1942</option>
 <option value=3D"1943">
1943</option>
 <option value==3D"1944">
1944</option>
 <option value=3D"1945">
1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
1948</option>
 <option value=3D"1949">
1949</option>
 <option value==3D"1950">
1950</option>
 <option value=3D"1951">
1951</option>
 <option value==3D"1952">
1952</option>
 <option value=3D"1953">
1953</option>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
 <option value=3D"1959">
1959</option>
 <option value==3D"1960">
1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
1976</option>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
 <option value==3D"1980">
1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
 <option value=3D"2011">
2011</option>
 <option value==3D"2012">
2012</option>
 <option value=3D"2013">
2013</option>
 <option value==3D"2014">
2014</option>
 <option value=3D"2015">
2015</option>
 <option value==3D"2016">
2016</option>
 <option value=3D"2017">
2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_206244955">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Hora de la Atenci=C3=B3n<label for=3D"m_2224155344718066861itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2224155344718066861ss-q-time">
<div class=3D"m_2224155344718066861ss-datetime-box m_2224155344718066861goog-inline-block" dir=3D"ltr" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
<select name=3D"entry.206244955_hour" disabled id=3D"m_2224155344718066861entry.206244955_hour">
<option value=3D"">
h</option>
<option value=3D"00">
00</option>
 <option value=3D"01">
01</option>
 <option value=3D"02">
02</option>
 <option value=3D"03">
03</option>
 <option value=3D"04">
04</option>
 <option value=3D"05">
05</option>
 <option value=3D"06">
06</option>
 <option value=3D"07">
07</option>
 <option value=3D"08">
08</option>
 <option value=3D"09">
09</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13" selected>
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value==3D"22">
22</option>
 <option value=3D"23">
23</option>
</select>
:<select name=3D"entry.206244955_minute" disabled id=3D"m_2224155344718066861entry.206244955_minute">
<option value=3D"">
min</option>
<option value=3D"00">
00</option>
 <option value=3D"01">
01</option>
 <option value=3D"02">
02</option>
 <option value=3D"03">
03</option>
 <option value=3D"04">
04</option>
 <option value=3D"05">
05</option>
 <option value=3D"06">
06</option>
 <option value=3D"07">
07</option>
 <option value=3D"08">
08</option>
 <option value=3D"09">
09</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15" selected>
15</option>
 <option value=3D"16">
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value==3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
 <option value=3D"32">
32</option>
 <option value=3D"33">
33</option>
 <option value=3D"34">
34</option>
 <option value=3D"35">
35</option>
 <option value=3D"36">
36</option>
 <option value=3D"37">
37</option>
 <option value=3D"38">
38</option>
 <option value=3D"39">
39</option>
 <option value=3D"40">
40</option>
 <option value=3D"41">
41</option>
 <option value=3D"42">
42</option>
 <option value=3D"43">
43</option>
 <option value=3D"44">
44</option>
 <option value=3D"45">
45</option>
 <option value=3D"46">
46</option>
 <option value=3D"47">
47</option>
 <option value=3D"48">
48</option>
 <option value=3D"49">
49</option>
 <option value=3D"50">
50</option>
 <option value=3D"51">
51</option>
 <option value=3D"52">
52</option>
 <option value=3D"53">
53</option>
 <option value=3D"54">
54</option>
 <option value=3D"55">
55</option>
 <option value=3D"56">
56</option>
 <option value=3D"57">
57</option>
 <option value=3D"58">
58</option>
 <option value=3D"59">
59</option>
</select>
<div class=3D"m_2224155344718066861ss-datetime-box-spacer m_2224155344718066861goog-inline-block" style=3D"height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-select" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_1747608258">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_2224155344718066861itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.1747608258" disabled id=3D"m_2224155344718066861entry_1747608258">
<option value=3D"">
</option>
<option value=3D"0" disabled>
0</option>
 <option value=3D"1" disabled selected>
1</option>
 <option value=3D"2" disabled>
2</option>
 <option value=3D"3" disabled>
3</option>
 <option value=3D"4" disabled>
4</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_1716090865">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_2224155344718066861entry_1421689035">
<tbody>
<tr>
<td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1421689035_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_2224155344718066861ss-scalerow m_2224155344718066861ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_2224155344718066861aria-todo">
</div>
</td>
<td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled checked value=3D"0" id=3D"m_2224155344718066861group_1421689035_1" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value==3D"1" id=3D"m_2224155344718066861group_1421689035_2" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"2" id=3D"m_2224155344718066861group_1421689035_3" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3" id=3D"m_2224155344718066861group_1421689035_4" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_2224155344718066861group_1421689035_5" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_2224155344718066861group_1421689035_6" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_2224155344718066861group_1421689035_7" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"7" id=3D"m_2224155344718066861group_1421689035_8" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_2224155344718066861group_1421689035_9" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_2224155344718066861group_1421689035_10" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class==3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name==3D"entry.1421689035" disabled value=3D"10" id=3D"m_2224155344718066861group_1421689035_11" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
<td class=3D"m_2224155344718066861ss-scalerow m_2224155344718066861ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_2064050596">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=A1ximo</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_2224155344718066861entry_1244707512">
<tbody>
<tr>
<td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_2224155344718066861ss-scalerow m_2224155344718066861ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_2224155344718066861aria-todo">
</div>
</td>
<td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"0" id=3D"m_2224155344718066861group_1244707512_1" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"1" id=3D"m_2224155344718066861group_1244707512_2" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"2" id=3D"m_2224155344718066861group_1244707512_3" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"3" id=3D"m_2224155344718066861group_1244707512_4" class==3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"4" id=3D"m_2224155344718066861group_1244707512_5" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"5" id=3D"m_2224155344718066861group_1244707512_6" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"6" id=3D"m_2224155344718066861group_1244707512_7" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled checked value=3D"7" id=3D"m_2224155344718066861group_1244707512_8" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"8" id=3D"m_2224155344718066861group_1244707512_9" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"9" id=3D"m_2224155344718066861group_1244707512_10" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class==3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name==3D"entry.1244707512" disabled value=3D"10" id=3D"m_2224155344718066861group_1244707512_11" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
<td class=3D"m_2224155344718066861ss-scalerow m_2224155344718066861ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_2000523015">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=ADnimo</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_2224155344718066861entry_853118630">
<tbody>
<tr>
<td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_853118630_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for==3D"m_2224155344718066861group_853118630_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_853118630_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_853118630_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class==3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_853118630_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_853118630_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_853118630_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_853118630_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_853118630_9" style==3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_853118630_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2224155344718066861ss-scalenumber" for=3D"m_2224155344718066861group_853118630_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_2224155344718066861ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_2224155344718066861ss-scalerow m_2224155344718066861ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_2224155344718066861aria-todo">
</div>
</td>
<td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled checked value=3D"0" id=3D"m_2224155344718066861group_853118630_1" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"1" id=3D"m_2224155344718066861group_853118630_2" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"2" id=3D"m_2224155344718066861group_853118630_3" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"3" id=3D"m_2224155344718066861group_853118630_4" class==3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"4" id=3D"m_2224155344718066861group_853118630_5" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"5" id=3D"m_2224155344718066861group_853118630_6" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"6" id=3D"m_2224155344718066861group_853118630_7" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"7" id=3D"m_2224155344718066861group_853118630_8" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"8" id=3D"m_2224155344718066861group_853118630_9" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"9" id=3D"m_2224155344718066861group_853118630_10" class=3D"m_2224155344718066861ss-q-radio">
</div>
</td>
 <td class=3D"m_2224155344718066861ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2224155344718066861ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"10" id=3D"m_2224155344718066861group_853118630_11" class==3D"m_2224155344718066861ss-q-radio">
</div>
</td>
<td class=3D"m_2224155344718066861ss-scalerow m_2224155344718066861ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_2140974612">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Anamnesis/Evoluci=C3=B3n<label for=3D"m_2224155344718066861itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2224155344718066861ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
PACIENTE EN CONDICIONES DE ESTABILIDAD INTERMITENTEEN CUANTO A MANEJO DE DOLOR, YA QUE REFIERE DOLOR LOCALIZADO QUE SE GENERA DURANTE LA POSICION DE SEDESTACION, PERO QUE SE ALIVIA POR COMPLETO DURANTE BIPEDESTACION Y POSICION DE DECUBITO DORSAL. POR LO QUE HA MANTENIDO ESTA ULTIMA LA MAYOR PARTE DEL TIEMPO.=20ULTIMAS 3 SESIONES DE RADIOTERAPIA HAN DEBIDO SER SUSPENDIDAS POR DOLOR EDEMA DE ZONA GENITAL, SECUNDARIAS A EFECTOS DE RADIACION ASOCIADO A BROTE DE HERPES ZOSTER.</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_824006088">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen F=C3=ADsico<label for=3D"m_2224155344718066861itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2224155344718066861ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
HEMODINAMIA ESTABLE, CLOTE COOPERADORAALIMENTANDOSE POR BOCA CON BUENA TOLERANCIA SIN PERDIDA DE PESOCARDIO NORMAL, PULMONAR NORMALABDOMEN BLANDO DEPRESIBLE, SENSIBLE EN HIPOGASTRIO MANTIENE INSERCION DE CISTO AUNQUE REFIERE RETIRO DE ESCASO CONTENIDO URINARIOREGION PERINE, AVO Y ERITEMA EN ZONA DE PUBIS SENSIBLE A PALPACION ASOCIADO A PAPULAS QUE SIGUEN DERMATOMA CON DOLOR TIPO ARDOR, QUE ABARCA LABIO MAYOR VAGINAL IZQUIERDO, ASOCIADO A ABUNDANTE ESCAPE DE ORINA Y ULCERA CANCEROSA DE ZONA .=20EXTREMIDADES SIN MANIFESTACIONES ACTUALES</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-text" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_1690694733">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_2224155344718066861itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2224155344718066861ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
CA URETRA, HERPES ZOSTER</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-item-required m_2224155344718066861ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_1255665248">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_2224155344718066861itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2224155344718066861ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2224155344718066861ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
SE INDICA MANEJO FARMACOLOGICO DE HERPES ZSE MANTIENEN ANALGESIA TRANSDERMICA + ANALGESIA ORAL=20SE MANTIENE TERAPIA BISEMANAL CON KINESIOLOGA PARA MANEJO Y FORTALECIMIENTO DE SUELO PELVICO Y MUSCULATURA</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_1648939075">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2224155344718066861ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
ACICLOVIR CREMA CADA 4 HRS X 5 DIASACICLOVIR COMPRIMIDOS 800 MG C/ 24 HRS X 5 DIASTRANSTEC 1/ PARCHE CADA 72 HRS=20PARACETAMOL 1 GRAMO CADA 8 HRS X 5 DIASKETOROLACO 10 MG C/ 8 HRS X 3 DIAS</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-date" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_2063615873">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2224155344718066861ss-q-date">
<div class=3D"m_2224155344718066861ss-datetime-box m_2224155344718066861goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name=3D"entry.2063615873_day" disabled class=3D"m_2224155344718066861ss-day-dropdown" id=3D"m_2224155344718066861entry.2063615873_day">
<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
 <option value=3D"2">
2</option>
 <option value=3D"3">
3</option>
 <option value=3D"4">
4</option>
 <option value=3D"5">
5</option>
 <option value=3D"6">
6</option>
 <option value=3D"7">
7</option>
 <option value=3D"8">
8</option>
 <option value=3D"9">
9</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value==3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
 <option value=3D"23" selected>
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
</select>
   <select name=3D"entry.2063615873_month" disabled class=3D"m_2224155344718066861ss-month-dropdown" id=3D"m_2224155344718066861entry.2063615873_month">
<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
 <option value=3D"2">
febrero</option>
 <option value=3D"3">
marzo</option>
 <option value=3D"4">
abril</option>
 <option value=3D"5">
mayo</option>
 <option value=3D"6">
junio</option>
 <option value==3D"7" selected>
julio</option>
 <option value=3D"8">
agosto</option>
 <option value=3D"9">
septiembre</option>
 <option value=3D"10">
octubre</option>
 <option value=3D"11">
noviembre</option>
 <option value=3D"12">
diciembre</option>
</select>
=20<select name=3D"entry.2063615873_year" disabled id=3D"m_2224155344718066861entry.2063615873_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
 <option value=3D"1898">
1898</option>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
1901</option>
 <option value=3D"1902">
1902</option>
 <option value=3D"1903">
1903</option>
 <option value=3D"1904">
1904</option>
 <option value=3D"1905">
1905</option>
 <option value=3D"1906">
1906</option>
 <option value=3D"1907">
1907</option>
 <option value=3D"1908">
1908</option>
 <option value=3D"1909">
1909</option>
 <option value=3D"1910">
1910</option>
 <option value=3D"1911">
1911</option>
 <option value=3D"1912">
1912</option>
 <option value=3D"1913">
1913</option>
 <option value=3D"1914">
1914</option>
 <option value=3D"1915">
1915</option>
 <option value=3D"1916">
1916</option>
 <option value=3D"1917">
1917</option>
 <option value=3D"1918">
1918</option>
 <option value=3D"1919">
1919</option>
 <option value=3D"1920">
1920</option>
 <option value=3D"1921">
1921</option>
 <option value=3D"1922">
1922</option>
 <option value=3D"1923">
1923</option>
 <option value==3D"1924">
1924</option>
 <option value=3D"1925">
1925</option>
 <option value==3D"1926">
1926</option>
 <option value=3D"1927">
1927</option>
 <option value==3D"1928">
1928</option>
 <option value=3D"1929">
1929</option>
 <option value==3D"1930">
1930</option>
 <option value=3D"1931">
1931</option>
 <option value==3D"1932">
1932</option>
 <option value=3D"1933">
1933</option>
 <option value==3D"1934">
1934</option>
 <option value=3D"1935">
1935</option>
 <option value==3D"1936">
1936</option>
 <option value=3D"1937">
1937</option>
 <option value==3D"1938">
1938</option>
 <option value=3D"1939">
1939</option>
 <option value==3D"1940">
1940</option>
 <option value=3D"1941">
1941</option>
 <option value==3D"1942">
1942</option>
 <option value=3D"1943">
1943</option>
 <option value==3D"1944">
1944</option>
 <option value=3D"1945">
1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
1948</option>
 <option value=3D"1949">
1949</option>
 <option value==3D"1950">
1950</option>
 <option value=3D"1951">
1951</option>
 <option value==3D"1952">
1952</option>
 <option value=3D"1953">
1953</option>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
 <option value=3D"1959">
1959</option>
 <option value==3D"1960">
1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
1976</option>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
 <option value==3D"1980">
1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
 <option value=3D"2011">
2011</option>
 <option value==3D"2012">
2012</option>
 <option value=3D"2013">
2013</option>
 <option value==3D"2014">
2014</option>
 <option value=3D"2015">
2015</option>
 <option value==3D"2016">
2016</option>
 <option value=3D"2017">
2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-text" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_74766472">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2224155344718066861ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861ss-form-question m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2224155344718066861ss-q-item-label" for=3D"m_2224155344718066861entry_1219705969">
<div class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_2224155344718066861ss-q-help m_2224155344718066861ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
</label>
<ul class=3D"m_2224155344718066861ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_2224155344718066861ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2224155344718066861ss-choice-item-control m_2224155344718066861goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"ENFERMERA" id=3D"m_2224155344718066861group_503039759_1" class=3D"m_2224155344718066861ss-q-checkbox">
</span>
<span class=3D"m_2224155344718066861ss-choice-label">
ENFERMERA</span>
</label>
</li>
 <li class=3D"m_2224155344718066861ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2224155344718066861ss-choice-item-control m_2224155344718066861goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_2224155344718066861group_503039759_2" class=3D"m_2224155344718066861ss-q-checkbox">
</span>
<span class=3D"m_2224155344718066861ss-choice-label">
TENS</span>
</label>
</li>
 <li class=3D"m_2224155344718066861ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2224155344718066861ss-choice-item-control m_2224155344718066861goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"NUTRICIONISTA" id=3D"m_2224155344718066861group_503039759_3" class=3D"m_2224155344718066861ss-q-checkbox">
</span>
<span class=3D"m_2224155344718066861ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
 <li class=3D"m_2224155344718066861ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2224155344718066861ss-choice-item-control m_2224155344718066861goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"KINESIOLOGO" id=3D"m_2224155344718066861group_503039759_4" class=3D"m_2224155344718066861ss-q-checkbox">
</span>
<span class=3D"m_2224155344718066861ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
 <li class=3D"m_2224155344718066861ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2224155344718066861ss-choice-item-control m_2224155344718066861goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"PSICOLOGO" id=3D"m_2224155344718066861group_503039759_5" class=3D"m_2224155344718066861ss-q-checkbox">
</span>
<span class=3D"m_2224155344718066861ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_2224155344718066861errorbox-good">
<div dir=3D"auto" class=3D"m_2224155344718066861ss-item m_2224155344718066861ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_2224155344718066861ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2224155344718066861ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_2224155344718066861ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
</form>
</div>
</div>
</td>
</tr>
<tr height=3D"24px">
</tr>
</tbody>
</table>
</div>
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"max-width:672px;min-width:154px" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242;font-size:13px" target=3D"_blank">
Crea tu propio formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
--000000000000326d35058de5e5d2--