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<img alt=3D"Formularios de Google" height==3D"26px" width=3D"143px" style=3D"display:inline-block; margin:0; vertical-align:middle" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
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<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" width=3D"100%" style=3D"background-color:#fff">
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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=F3n Domiciliaria Oncovida</a>
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Esto es lo que nos has enviado:</div>
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<div class=3D"m_-7321647350366336890ss-form-container">
<div class=3D"m_-7321647350366336890ss-form-heading">
<h1 class=3D"m_-7321647350366336890ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=F3n Domiciliaria Oncovida</h1>
<div class=3D"m_-7321647350366336890ss-form-desc m_-7321647350366336890ss-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=F3n indique su correo electr=F3nico.</div>
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<div class=3D"m_-7321647350366336890ss-form">
<form method=3D"GET" id=3D"m_-7321647350366336890ss-form" target=3D"_blank">
<br>
<div class=3D"m_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-item-required m_-7321647350366336890ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890emailAddress">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Direcci=F3n de correo electr=F3nico <label for=3D"m_-7321647350366336890emailAddress">
</label>
<span class=3D"m_-7321647350366336890ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_-7321647350366336890ss-q-text m_-7321647350366336890ss-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:fasupaz@gmail.com" target=3D"_blank">
fasupaz@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-embeddable-object-container" style=3D"margin:12px 0; max-width:100%">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"m_-7321647350366336890ss-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_-7321647350366336890ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ">
</div>
</div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"m_-7321647350366336890ss-page-title" style=3D"padding:0.4em; background-color:#eee">
Identificaci=F3n del Prestador</h2>
<div class=3D"m_-7321647350366336890ss-page-description m_-7321647350366336890ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap; word-wrap:break-word">
Aqu=ED debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-item-required m_-7321647350366336890ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_579114469">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Primer Nombre y Apellido Paterno <label for=3D"m_-7321647350366336890itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7321647350366336890ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"m_-7321647350366336890ss-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%">
fabiola asenjo</div>
</div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-item-required m_-7321647350366336890ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_1276273985">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
RUT <label for=3D"m_-7321647350366336890itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7321647350366336890ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
RUT con Gui=F3n y D=EDgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_-7321647350366336890ss-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%">
12108077-k</div>
</div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-item-required m_-7321647350366336890ss-select" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_133691676">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Tipo <label for=3D"m_-7321647350366336890itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7321647350366336890ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
Si asisten m=E1s de 1 prestador simult=E1neamente, cada uno debe hacer un registro independiente</div>
</label>
<select name=3D"entry.133691676" disabled=3D"" id=3D"m_-7321647350366336890entry_133691676">
<option value=3D"">
</option>
 <option value=3D"MEDICO" disabled=3D"" selected=3D"">
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled=3D"">
ENFERMERA/O</option>
 <option value=3D"TENS" disabled=3D"">
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled=3D"">
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled=3D"">
PSICOLOGO</option>
 <option value=3D"NUTRICIONISTA" disabled=3D"">
NUTRICIONISTA</option>
</select>
 </div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-embeddable-object-container" style=3D"margin:12px 0; max-width:100%">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"m_-7321647350366336890ss-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_-7321647350366336890ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA">
</div>
</div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"m_-7321647350366336890ss-page-title" style=3D"padding:0.4em; background-color:#eee">
Identificaci=F3n del Paciente</h2>
<div class=3D"m_-7321647350366336890ss-page-description m_-7321647350366336890ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap; word-wrap:break-word">
En esta secci=F3n debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"m_-7321647350366336890ss-section-title" style=3D"background-color:#eee; padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_-7321647350366336890ss-section-description m_-7321647350366336890ss-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_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-item-required m_-7321647350366336890ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_823811303">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Ingrese el Rut del Paciente <label for=3D"m_-7321647350366336890itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7321647350366336890ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
RUT con Gui=F3n y D=EDgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_-7321647350366336890ss-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%">
8699860-2</div>
</div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-item-required m_-7321647350366336890ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_1959365839">
<div class=3D"m_-7321647350366336890ss-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_-7321647350366336890itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7321647350366336890ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"m_-7321647350366336890ss-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%">
Viola Ojeda</div>
</div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-item-required m_-7321647350366336890ss-select" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_545002227">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Previsi=F3n <label for=3D"m_-7321647350366336890itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7321647350366336890ss-required-asterisk" style==3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<select name=3D"entry.545002227" disabled=3D"" id=3D"m_-7321647350366336890entry_545002227">
<option value=3D"">
</option>
 <option value=3D"BANMEDICA" disabled=3D"">
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled=3D"">
CAPREDENA</option>
 <option value=3D"COLMENA" disabled=3D"">
COLMENA</option>
 <option value=3D"CONSALUD" disabled=3D"" selected=3D"">
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled=3D"">
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled=3D"">
DIPRECA</option>
 <option value=3D"FONASA" disabled=3D"">
FONASA</option>
 <option value=3D"FUNDACION" disabled=3D"">
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled=3D"">
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled=3D"">
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled=3D"">
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled=3D"">
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-item-required m_-7321647350366336890ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_1900161356">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Ciudad <label for=3D"m_-7321647350366336890itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7321647350366336890ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"m_-7321647350366336890ss-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%">
Osorno</div>
</div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-item-required m_-7321647350366336890ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_1298871758">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Comuna <label for=3D"m_-7321647350366336890itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7321647350366336890ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"m_-7321647350366336890ss-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%">
Osorno </div>
</div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-embeddable-object-container" style=3D"margin:12px 0; max-width:100%">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"m_-7321647350366336890ss-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_-7321647350366336890ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ">
</div>
</div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"m_-7321647350366336890ss-page-title" style=3D"padding:0.4em; background-color:#eee">
Registro de la Atenci=F3n Domiciliaria</h2>
<div class=3D"m_-7321647350366336890ss-page-description m_-7321647350366336890ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap; word-wrap:break-word">
En esta secci=F3n debe ingresar los datos de la atenci=F3n domiciliaria</div>
</div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-item-required m_-7321647350366336890ss-radio" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_2073233714">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Tipo de Atenci=F3n <label for=3D"m_-7321647350366336890itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7321647350366336890ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<ul class=3D"m_-7321647350366336890ss-choices" style=3D"list-style:none; padding:0; margin:.5em 0 0">
<li class=3D"m_-7321647350366336890ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"m_-7321647350366336890ss-choice-item-control m_-7321647350366336890goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled=3D"" checked=3D"" value=3D"Domicilio" id=3D"m_-7321647350366336890group_1222378237_1" class=3D"m_-7321647350366336890ss-q-radio">
</span>
<span class=3D"m_-7321647350366336890ss-choice-label">
Domicilio</span>
 </label>
</li>
<li class=3D"m_-7321647350366336890ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"m_-7321647350366336890ss-choice-item-control m_-7321647350366336890goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled=3D"" value=3D"Ambulatorio" id=3D"m_-7321647350366336890group_1222378237_2" class=3D"m_-7321647350366336890ss-q-radio">
</span>
<span class=3D"m_-7321647350366336890ss-choice-label">
Ambulatorio</span>
 </label>
</li>
</ul>
</div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-item-required m_-7321647350366336890ss-date" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_1705849412">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Fecha de la Atenci=F3n <label for=3D"m_-7321647350366336890itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7321647350366336890ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"m_-7321647350366336890ss-q-date">
<div class=3D"m_-7321647350366336890ss-datetime-box m_-7321647350366336890goog-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=3D"" class=3D"m_-7321647350366336890ss-day-dropdown" id=3D"m_-7321647350366336890entry.1705849412_day">
<option value=3D"">
D=EDa</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" selected=3D"">
15</option>
 <option value=3D"16">
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
</select>
 <select name=3D"entry.1705849412_month" disabled=3D"" class=3D"m_-7321647350366336890ss-month-dropdown" id=3D"m_-7321647350366336890entry.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=3D"">
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>
<select name=3D"entry.1705849412_year" disabled=3D"" id=3D"m_-7321647350366336890entry.1705849412_year">
<option value=3D"">
A=F1o</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=3D"">
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_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-item-required m_-7321647350366336890ss-time" style=3D"margin:12px 0; font:inherit">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_206244955">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Hora de la Atenci=F3n <label for=3D"m_-7321647350366336890itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7321647350366336890ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"m_-7321647350366336890ss-q-time">
<div class=3D"m_-7321647350366336890ss-datetime-box m_-7321647350366336890goog-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=3D"" id=3D"m_-7321647350366336890entry.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">
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" selected=3D"">
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=3D"" id=3D"m_-7321647350366336890entry.206244955_minute">
<option value=3D"">
min</option>
 <option value=3D"00" selected=3D"">
00</option>
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01</option>
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02</option>
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03</option>
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04</option>
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05</option>
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06</option>
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07</option>
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08</option>
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09</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
 <option value=3D"18">
18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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32</option>
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33</option>
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34</option>
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35</option>
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36</option>
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37</option>
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38</option>
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39</option>
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40</option>
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41</option>
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42</option>
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43</option>
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44</option>
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45</option>
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46</option>
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47</option>
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48</option>
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49</option>
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50</option>
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51</option>
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52</option>
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53</option>
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54</option>
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55</option>
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56</option>
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57</option>
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58</option>
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59</option>
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<div class=3D"m_-7321647350366336890ss-datetime-box-spacer m_-7321647350366336890goog-inline-block" style=3D"height:32px; vertical-align:middle; display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-item-required m_-7321647350366336890ss-select" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_1747608258">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Performance Status ECOG del Paciente <label for=3D"m_-7321647350366336890itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7321647350366336890ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<select name=3D"entry.1747608258" disabled=3D"" id=3D"m_-7321647350366336890entry_1747608258">
<option value=3D"">
</option>
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0</option>
 <option value=3D"1" disabled=3D"">
1</option>
 <option value=3D"2" disabled=3D"" selected=3D"">
2</option>
 <option value=3D"3" disabled=3D"">
3</option>
 <option value=3D"4" disabled=3D"">
4</option>
</select>
 </div>
</div>
</div>
<br>
<div class=3D"m_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-scale" style=3D"margin:12px 0; overflow-x:auto">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_1716090865">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Escala Dolor EVA Actual </div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-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_-7321647350366336890entry_1421689035">
<tbody>
<tr>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1421689035_1" style=3D"display:block; padding:0.5em 0 .5em">
0</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1421689035_2" style=3D"display:block; padding:0.5em 0 .5em">
1</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1421689035_3" style=3D"display:block; padding:0.5em 0 .5em">
2</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1421689035_4" style=3D"display:block; padding:0.5em 0 .5em">
3</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1421689035_5" style=3D"display:block; padding:0.5em 0 .5em">
4</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1421689035_6" style=3D"display:block; padding:0.5em 0 .5em">
5</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1421689035_7" style=3D"display:block; padding:0.5em 0 .5em">
6</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1421689035_8" style=3D"display:block; padding:0.5em 0 .5em">
7</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1421689035_9" style=3D"display:block; padding:0.5em 0 .5em">
8</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1421689035_10" style=3D"display:block; padding:0.5em 0 .5em">
9</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1421689035_11" style=3D"display:block; padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-7321647350366336890ss-scalerow m_-7321647350366336890ss-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_-7321647350366336890aria-todo">
</div>
</td>
<td class=3D"m_-7321647350366336890ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
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<input type=3D"radio" name=3D"entry.1421689035" disabled=3D"" value=3D"0" id=3D"m_-7321647350366336890group_1421689035_1" class=3D"m_-7321647350366336890ss-q-radio">
</div>
</td>
<td class=3D"m_-7321647350366336890ss-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_-7321647350366336890ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled=3D"" value=3D"1" id=3D"m_-7321647350366336890group_1421689035_2" class=3D"m_-7321647350366336890ss-q-radio">
</div>
</td>
<td class=3D"m_-7321647350366336890ss-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_-7321647350366336890ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled=3D"" value=3D"2" id=3D"m_-7321647350366336890group_1421689035_3" class=3D"m_-7321647350366336890ss-q-radio">
</div>
</td>
<td class=3D"m_-7321647350366336890ss-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_-7321647350366336890ss-scalerow-fieldcell">
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</div>
</td>
<td class=3D"m_-7321647350366336890ss-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_-7321647350366336890ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled=3D"" value=3D"4" id=3D"m_-7321647350366336890group_1421689035_5" class=3D"m_-7321647350366336890ss-q-radio">
</div>
</td>
<td class=3D"m_-7321647350366336890ss-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_-7321647350366336890ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled=3D"" value=3D"5" id=3D"m_-7321647350366336890group_1421689035_6" class=3D"m_-7321647350366336890ss-q-radio">
</div>
</td>
<td class=3D"m_-7321647350366336890ss-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_-7321647350366336890ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled=3D"" value=3D"6" id=3D"m_-7321647350366336890group_1421689035_7" class=3D"m_-7321647350366336890ss-q-radio">
</div>
</td>
<td class=3D"m_-7321647350366336890ss-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_-7321647350366336890ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled=3D"" value=3D"7" id=3D"m_-7321647350366336890group_1421689035_8" class=3D"m_-7321647350366336890ss-q-radio">
</div>
</td>
<td class=3D"m_-7321647350366336890ss-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_-7321647350366336890ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled=3D"" value=3D"8" id=3D"m_-7321647350366336890group_1421689035_9" class=3D"m_-7321647350366336890ss-q-radio">
</div>
</td>
<td class=3D"m_-7321647350366336890ss-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_-7321647350366336890ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled=3D"" value=3D"9" id=3D"m_-7321647350366336890group_1421689035_10" class=3D"m_-7321647350366336890ss-q-radio">
</div>
</td>
<td class=3D"m_-7321647350366336890ss-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_-7321647350366336890ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled=3D"" value=3D"10" id=3D"m_-7321647350366336890group_1421689035_11" class=3D"m_-7321647350366336890ss-q-radio">
</div>
</td>
<td class=3D"m_-7321647350366336890ss-scalerow m_-7321647350366336890ss-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_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-scale" style=3D"margin:12px 0; overflow-x:auto">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_2064050596">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Escala Dolor EVA M=E1ximo </div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-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_-7321647350366336890entry_1244707512">
<tbody>
<tr>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1244707512_1" style=3D"display:block; padding:0.5em 0 .5em">
0</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1244707512_2" style=3D"display:block; padding:0.5em 0 .5em">
1</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1244707512_3" style=3D"display:block; padding:0.5em 0 .5em">
2</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1244707512_4" style=3D"display:block; padding:0.5em 0 .5em">
3</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1244707512_5" style=3D"display:block; padding:0.5em 0 .5em">
4</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1244707512_6" style=3D"display:block; padding:0.5em 0 .5em">
5</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1244707512_7" style=3D"display:block; padding:0.5em 0 .5em">
6</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1244707512_8" style=3D"display:block; padding:0.5em 0 .5em">
7</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1244707512_9" style=3D"display:block; padding:0.5em 0 .5em">
8</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1244707512_10" style=3D"display:block; padding:0.5em 0 .5em">
9</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_1244707512_11" style=3D"display:block; padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-7321647350366336890ss-scalerow m_-7321647350366336890ss-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_-7321647350366336890aria-todo">
</div>
</td>
<td class=3D"m_-7321647350366336890ss-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_-7321647350366336890ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled=3D"" value=3D"0" id=3D"m_-7321647350366336890group_1244707512_1" class=3D"m_-7321647350366336890ss-q-radio">
</div>
</td>
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Escala Dolor EVA M=EDnimo </div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
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<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_853118630_1" style=3D"display:block; padding:0.5em 0 .5em">
0</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_853118630_2" style=3D"display:block; padding:0.5em 0 .5em">
1</label>
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<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_853118630_3" style=3D"display:block; padding:0.5em 0 .5em">
2</label>
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<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_853118630_4" style=3D"display:block; padding:0.5em 0 .5em">
3</label>
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<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_853118630_5" style=3D"display:block; padding:0.5em 0 .5em">
4</label>
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<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_853118630_6" style=3D"display:block; padding:0.5em 0 .5em">
5</label>
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<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_853118630_7" style=3D"display:block; padding:0.5em 0 .5em">
6</label>
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<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_853118630_8" style=3D"display:block; padding:0.5em 0 .5em">
7</label>
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<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_853118630_9" style=3D"display:block; padding:0.5em 0 .5em">
8</label>
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<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_853118630_10" style=3D"display:block; padding:0.5em 0 .5em">
9</label>
</td>
<td class=3D"m_-7321647350366336890ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7321647350366336890ss-scalenumber" for=3D"m_-7321647350366336890group_853118630_11" style=3D"display:block; padding:0.5em 0 .5em">
10</label>
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</td>
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<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_2140974612">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Anamnesis/Evoluci=F3n <label for=3D"m_-7321647350366336890itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7321647350366336890ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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</div>
</label>
<div class=3D"m_-7321647350366336890ss-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 Viola , se encuentra levantada , buen estado general , deambula sin dificultad sin apoyo . &gt;Hoy se encuentra sola . Refiere sensaci=F3n de plenitud g=E1strica y dispepsia, Mantiene dolor abdominal en hipocondrio derecho , as=ED como masa abdominal que le molesta y le duele Sin aumento en la frecuencia de deposiciones sin cambios en consistencia , sin melena ni acolia refiere haber sido evaluad por nutricionista</div>
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<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_824006088">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Examen F=EDsico <label for=3D"m_-7321647350366336890itemView.getDomIdToLabel()">
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*</span>
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</div>
</label>
<div class=3D"m_-7321647350366336890ss-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%">
TA 160/72 fc /74 Hepatomegalia 5 dedos bajo reborde costal dolorosa a la palpaci=F3n , sin ascitis , rha y timpanismo &#43;&#43; Leve tinte icterico en piel . Mucosas palidas Extremidades ; presenta edema &#43; bilateral CV : RR 2t sin soplo Pulmonar Mv conservado sin estertores , sin retraccion . </div>
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<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_1690694733">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Diagn=F3stico <label for=3D"m_-7321647350366336890itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7321647350366336890ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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</div>
</label>
<div class=3D"m_-7321647350366336890ss-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%">
Cancer de vesicular , con sintomatologia digestiva </div>
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Plan de Tratamiento e Indicaciones <label for=3D"m_-7321647350366336890itemView.getDomIdToLabel()">
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Alimentaci=F3n fraccionada , seg=FAn indicaci=F3n de nutricionista Control con medico en dos semanas debido a nivel de EVA y ECOG actual Control medico SOS si se detecta cambios en estado cl=EDnico , aumento EVA o ECOG.</div>
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Medicamentos Indicados </div>
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Paracetamol 1 grm diario o cada 12 hrs seg=FAn dolor Metoclopamida 10 mg 30 minutos antes de almuerzo y cena Lactulosa 5 cc dia sos</div>
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Fecha aproximada del Pr=F3ximo Control con usted </div>
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<div class=3D"m_-7321647350366336890ss-datetime-box m_-7321647350366336890goog-inline-block" style=3D"border:1px solid #dcdcdc; margin-right:2em; min-height:32px; padding-left:3px; vertical-align:middle; margin:4px 3px; display:inline-block">
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D=EDa</option>
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1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
<option value=3D"30">
30</option>
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31</option>
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<option value=3D"">
Mes</option>
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enero</option>
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febrero</option>
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marzo</option>
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abril</option>
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mayo</option>
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junio</option>
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julio</option>
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agosto</option>
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septiembre</option>
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1896</option>
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1897</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
<option value=3D"1933">
1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
<option value=3D"1938">
1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
<option value=3D"1943">
1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
<option value=3D"1998">
1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
<option value=3D"2003">
2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
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2019</option>
<option value=3D"2020">
2020</option>
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2021</option>
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2022</option>
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2023</option>
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2024</option>
<option value=3D"2025">
2025</option>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
<option value=3D"2030">
2030</option>
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2031</option>
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2032</option>
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2033</option>
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2034</option>
<option value=3D"2035">
2035</option>
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2036</option>
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2037</option>
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2038</option>
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2039</option>
<option value=3D"2040">
2040</option>
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2041</option>
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2042</option>
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2043</option>
 <option value=3D"2044">
2044</option>
<option value=3D"2045">
2045</option>
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2046</option>
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2047</option>
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2048</option>
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2049</option>
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2050</option>
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2051</option>
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2052</option>
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2053</option>
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2054</option>
<option value=3D"2055">
2055</option>
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2056</option>
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2057</option>
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2058</option>
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2059</option>
<option value=3D"2060">
2060</option>
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2061</option>
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2062</option>
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2063</option>
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2064</option>
<option value=3D"2065">
2065</option>
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2066</option>
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2067</option>
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2068</option>
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2069</option>
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<div class=3D"m_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-text" style=3D"margin:12px 0">
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Tratamiento Realizado (si corresponde) </div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"m_-7321647350366336890ss-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_-7321647350366336890ss-form-question m_-7321647350366336890errorbox-good">
<div dir=3D"auto" class=3D"m_-7321647350366336890ss-item m_-7321647350366336890ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_-7321647350366336890ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"m_-7321647350366336890ss-q-item-label" for=3D"m_-7321647350366336890entry_1219705969">
<div class=3D"m_-7321647350366336890ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Derivaci=F3n a otro Prestador Domiciliario </div>
<div class=3D"m_-7321647350366336890ss-q-help m_-7321647350366336890ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
S=F3lo llene esta secci=F3n si es m=E9dico y solicita la visita de otro prestador del equipo</div>
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<label>
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ENFERMERA</span>
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<label>
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<input type=3D"checkbox" name=3D"entry.503039759" disabled=3D"" value=3D"TENS" id=3D"m_-7321647350366336890group_503039759_2" class=3D"m_-7321647350366336890ss-q-checkbox">
</span>
<span class=3D"m_-7321647350366336890ss-choice-label">
TENS</span>
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<li class=3D"m_-7321647350366336890ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
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<input type=3D"checkbox" name=3D"entry.503039759" disabled=3D"" checked=3D"" value=3D"NUTRICIONISTA" id=3D"m_-7321647350366336890group_503039759_3" class=3D"m_-7321647350366336890ss-q-checkbox">
</span>
<span class=3D"m_-7321647350366336890ss-choice-label">
NUTRICIONISTA</span>
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<label>
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<input type=3D"checkbox" name=3D"entry.503039759" disabled=3D"" value=3D"KINESIOLOGO" id=3D"m_-7321647350366336890group_503039759_4" class=3D"m_-7321647350366336890ss-q-checkbox">
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<span class=3D"m_-7321647350366336890ss-choice-label">
KINESIOLOGO</span>
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<label>
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PSICOLOGO</span>
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<h2 class=3D"m_-7321647350366336890ss-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_-7321647350366336890ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A">
</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" width=3D"100%" style=3D"max-width:672px; min-width:154px">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" target==3D"_blank" style=3D"color:#424242; font-size:13px">
Crea tu propio formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br clear=3D"all">
<div>
<br>
</div>
-- <br>
<div dir=3D"ltr" class=3D"gmail_signature">
<div dir=3D"ltr">
<br>
<div style=3D"text-align:center">
<font face=3D"comic sans ms, sans-serif" size=3D"2" color=3D"#351c75">
Saludos cordiales&nbsp;</font>
</div>
<div style=3D"text-align:center">
<font face=3D"comic sans ms, sans-serif" size=3D"2" color=3D"#351c75">
Fabiola Asenjo &nbsp;Casas</font>
</div>
</div>
</div>
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</div>
</body>
</html>
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