<div dir=3D"auto">
</div>
<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: jue., 25 jul. 2019 23:11<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:eveortegaa@gmail.com">
eveortegaa@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" rel=3D"noreferrer">
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_1687355139881589010ss-form-container">
<div class=3D"m_1687355139881589010ss-form-heading">
<h1 class=3D"m_1687355139881589010ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_1687355139881589010ss-form-desc m_1687355139881589010ss-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_1687355139881589010ss-form">
<form method=3D"GET" id=3D"m_1687355139881589010ss-form" target=3D"_blank">
<br>
<div class=3D"m_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-item-required m_1687355139881589010ss-text" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010emailAddress">
<div class=3D"m_1687355139881589010ss-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_1687355139881589010emailAddress">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_1687355139881589010ss-q-text m_1687355139881589010ss-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:eveortegaa@gmail.com" target=3D"_blank" rel=3D"noreferrer">
eveortegaa@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1687355139881589010ss-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_1687355139881589010ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/00-FWRRIiJNpjLIXj1QrTLVceHhiPxWpIN-K4cI0enEtAvmFFnvOHRJTMz5Lq8yFpMHz7WvBnNdiNVchE6Snklpxxc7gIx3OoqTfn_sB2_iSp_6sx7Sr2pww-0pD" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1687355139881589010ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_1687355139881589010ss-page-description m_1687355139881589010ss-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_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-item-required m_1687355139881589010ss-text" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_579114469">
<div class=3D"m_1687355139881589010ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_1687355139881589010itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1687355139881589010ss-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%">
Evelyn Ortega</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-item-required m_1687355139881589010ss-text" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_1276273985">
<div class=3D"m_1687355139881589010ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_1687355139881589010itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-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_1687355139881589010ss-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%">
16273226-9</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-item-required m_1687355139881589010ss-select" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_133691676">
<div class=3D"m_1687355139881589010ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_1687355139881589010itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-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_1687355139881589010entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled selected>
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_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1687355139881589010ss-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_1687355139881589010ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/mRJInQVKRU12r9blREv2jmlzETLT9JfIHWC0FaeXYfPraPFE9ebBRX8P_hmpfiBP6BNpOgjPBYU0zwBxYxgoLvjQ7EjfjoRTJ2_-8flTaiU_wC008XC8LpcEJ_Yp" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1687355139881589010ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_1687355139881589010ss-page-description m_1687355139881589010ss-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_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1687355139881589010ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_1687355139881589010ss-section-description m_1687355139881589010ss-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_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-item-required m_1687355139881589010ss-text" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_823811303">
<div class=3D"m_1687355139881589010ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_1687355139881589010itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-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_1687355139881589010ss-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%">
10560826-9</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-item-required m_1687355139881589010ss-text" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_1959365839">
<div class=3D"m_1687355139881589010ss-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_1687355139881589010itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1687355139881589010ss-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%">
Marcela Contreras</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-item-required m_1687355139881589010ss-select" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_545002227">
<div class=3D"m_1687355139881589010ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_1687355139881589010itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-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_1687355139881589010entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled selected>
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_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-item-required m_1687355139881589010ss-text" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_1900161356">
<div class=3D"m_1687355139881589010ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_1687355139881589010itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1687355139881589010ss-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%">
Linares</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-item-required m_1687355139881589010ss-text" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_1298871758">
<div class=3D"m_1687355139881589010ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_1687355139881589010itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1687355139881589010ss-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%">
Linares</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1687355139881589010ss-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_1687355139881589010ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/URytM0QWRGW_JEL0xQxvOLvwPRJIHyqlnKOm6ky9DRBfzvYVPaAngXV35GNHnaVG-dm9Orno4lr8sy8E-KB9tMrmIhFbVQiOPWy3vUclqRKAJ51dvLdhjBKgXdLO" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1687355139881589010ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_1687355139881589010ss-page-description m_1687355139881589010ss-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_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-item-required m_1687355139881589010ss-radio" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_2073233714">
<div class=3D"m_1687355139881589010ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_1687355139881589010itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_1687355139881589010ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_1687355139881589010ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_1687355139881589010ss-choice-item-control m_1687355139881589010goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_1687355139881589010group_1222378237_1" class=3D"m_1687355139881589010ss-q-radio">
</span>
<span class=3D"m_1687355139881589010ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_1687355139881589010ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_1687355139881589010ss-choice-item-control m_1687355139881589010goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_1687355139881589010group_1222378237_2" class=3D"m_1687355139881589010ss-q-radio">
</span>
<span class=3D"m_1687355139881589010ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-item-required m_1687355139881589010ss-date" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_1705849412">
<div class=3D"m_1687355139881589010ss-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_1687355139881589010itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1687355139881589010ss-q-date">
<div class=3D"m_1687355139881589010ss-datetime-box m_1687355139881589010goog-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_1687355139881589010ss-day-dropdown" id=3D"m_1687355139881589010entry.1705849412_day">
<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
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>
 <option value=3D"31">
31</option>
</select>
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<option value=3D"">
Mes</option>
<option value=3D"1">
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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octubre</option>
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noviembre</option>
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diciembre</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_1687355139881589010entry.1705849412_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
 <option value==3D"1932">
1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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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>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
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1959</option>
 <option value==3D"1960">
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>
 <option value=3D"1973">
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>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
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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>
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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>
 <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>
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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>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
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2020</option>
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2021</option>
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2022</option>
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2023</option>
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2024</option>
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2025</option>
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2026</option>
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2027</option>
 <option value=3D"2028">
2028</option>
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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>
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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>
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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>
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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_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-item-required m_1687355139881589010ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_206244955">
<div class=3D"m_1687355139881589010ss-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_1687355139881589010itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1687355139881589010ss-q-time">
<div class=3D"m_1687355139881589010ss-datetime-box m_1687355139881589010goog-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_1687355139881589010entry.206244955_hour">
<option value=3D"">
h</option>
<option value=3D"00">
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>
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18</option>
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19</option>
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20</option>
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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_1687355139881589010entry.206244955_minute">
<option value=3D"">
min</option>
<option value=3D"00" selected>
00</option>
 <option value=3D"01">
01</option>
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02</option>
 <option value=3D"03">
03</option>
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04</option>
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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>
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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">
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>
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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>
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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>
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59</option>
</select>
<div class=3D"m_1687355139881589010ss-datetime-box-spacer m_1687355139881589010goog-inline-block" style=3D"height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-item-required m_1687355139881589010ss-select" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_1747608258">
<div class=3D"m_1687355139881589010ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_1687355139881589010itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
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</div>
</label>
<select name=3D"entry.1747608258" disabled id=3D"m_1687355139881589010entry_1747608258">
<option value=3D"">
</option>
<option value=3D"0" disabled>
0</option>
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1</option>
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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_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_1716090865">
<div class=3D"m_1687355139881589010ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-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_1687355139881589010entry_1421689035">
<tr>
<td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1421689035_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_1687355139881589010ss-scalerow m_1687355139881589010ss-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_1687355139881589010aria-todo">
</div>
</td>
<td class=3D"m_1687355139881589010ss-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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</div>
</td>
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<div class=3D"m_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"1" id=3D"m_1687355139881589010group_1421689035_2" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
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<div class=3D"m_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"2" id=3D"m_1687355139881589010group_1421689035_3" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
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<div class=3D"m_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3" id=3D"m_1687355139881589010group_1421689035_4" class==3D"m_1687355139881589010ss-q-radio">
</div>
</td>
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<div class=3D"m_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_1687355139881589010group_1421689035_5" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
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<div class=3D"m_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_1687355139881589010group_1421689035_6" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_1687355139881589010group_1421689035_7" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
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</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_1687355139881589010group_1421689035_9" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
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<div class=3D"m_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_1687355139881589010group_1421689035_10" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name==3D"entry.1421689035" disabled value=3D"10" id=3D"m_1687355139881589010group_1421689035_11" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
<td class=3D"m_1687355139881589010ss-scalerow m_1687355139881589010ss-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>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_2064050596">
<div class=3D"m_1687355139881589010ss-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_1687355139881589010ss-q-help m_1687355139881589010ss-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_1687355139881589010entry_1244707512">
<tr>
<td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_1687355139881589010ss-scalerow m_1687355139881589010ss-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_1687355139881589010aria-todo">
</div>
</td>
<td class=3D"m_1687355139881589010ss-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.1244707512" disabled value=3D"0" id=3D"m_1687355139881589010group_1244707512_1" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"1" id=3D"m_1687355139881589010group_1244707512_2" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
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</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"3" id=3D"m_1687355139881589010group_1244707512_4" class==3D"m_1687355139881589010ss-q-radio">
</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"4" id=3D"m_1687355139881589010group_1244707512_5" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"5" id=3D"m_1687355139881589010group_1244707512_6" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
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</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
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</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
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</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"9" id=3D"m_1687355139881589010group_1244707512_10" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled checked value=3D"10" id=3D"m_1687355139881589010group_1244707512_11" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
<td class=3D"m_1687355139881589010ss-scalerow m_1687355139881589010ss-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>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_2000523015">
<div class=3D"m_1687355139881589010ss-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_1687355139881589010ss-q-help m_1687355139881589010ss-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_1687355139881589010entry_853118630">
<tr>
<td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_853118630_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for==3D"m_1687355139881589010group_853118630_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_853118630_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_853118630_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class==3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_853118630_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_853118630_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_853118630_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_853118630_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_853118630_9" style==3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_853118630_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1687355139881589010ss-scalenumber" for=3D"m_1687355139881589010group_853118630_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_1687355139881589010ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_1687355139881589010ss-scalerow m_1687355139881589010ss-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_1687355139881589010aria-todo">
</div>
</td>
<td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"0" id=3D"m_1687355139881589010group_853118630_1" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"1" id=3D"m_1687355139881589010group_853118630_2" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
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<div class=3D"m_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value==3D"2" id=3D"m_1687355139881589010group_853118630_3" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
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<div class=3D"m_1687355139881589010ss-scalerow-fieldcell">
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</div>
</td>
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<div class=3D"m_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled checked value=3D"4" id=3D"m_1687355139881589010group_853118630_5" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
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<div class=3D"m_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"5" id=3D"m_1687355139881589010group_853118630_6" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
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<div class=3D"m_1687355139881589010ss-scalerow-fieldcell">
<input type==3D"radio" name=3D"entry.853118630" disabled value=3D"6" id=3D"m_1687355139881589010group_853118630_7" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"7" id=3D"m_1687355139881589010group_853118630_8" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"8" id=3D"m_1687355139881589010group_853118630_9" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"9" id=3D"m_1687355139881589010group_853118630_10" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
 <td class=3D"m_1687355139881589010ss-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_1687355139881589010ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"10" id=3D"m_1687355139881589010group_853118630_11" class=3D"m_1687355139881589010ss-q-radio">
</div>
</td>
<td class=3D"m_1687355139881589010ss-scalerow m_1687355139881589010ss-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>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-item-required m_1687355139881589010ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_2140974612">
<div class=3D"m_1687355139881589010ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Anamnesis/Evoluci=C3=B3n<label for=3D"m_1687355139881589010itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1687355139881589010ss-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 orientada en tiempo y espacio, deambula lento debido a dolor pierna izquierda, gluteos, de animo bajo, deca=C3=ADda, dolor de pierna izquierda  y espalda EVA  7/10 , durante la semana  ha presentado episodios de dolor muy fuerte que ha llorado de dolor.Apetito: inapetente, consume sus alimentos (desayuno, almuerzo y once) abundante aguaNauseas: (-)Vomitos: (-)Sue=C3=B1o: refiere que durante la noche tiene sue=C3=B1o interrumpido debido que despierta por deseos de orinar mas de 6 veces=20Diuresis: (+) aumento de frecuencia durante dia y noche, y ardor al terminar de orinarDeposiciones: (-) refiere que no evacua hace dos diasSecrecion vaginal: (+) continua con secrecion de color verde   sin olor.Picazon: (-)Dolor de pelvis: (+) EVA 4/10Dolor de espalda: (+) EVA 8/10Dolor pierna izquierda: EVA 7/10Meteorismo: (-)Calambres: (+)Refiere que el dia martes 23/07  fue al neurocirujano en la Clinica Lircay el cual le indico examenes de orina completa, urocultivo  al terminar el tratamiento para la infeccion urinaria, junto con un Electromiografia que se realizara el dia 26 de agosto. Ademas le indico nuevos medicamentos, norspam, nitrofurantoina, detrulcam, dropol.</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-item-required m_1687355139881589010ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_824006088">
<div class=3D"m_1687355139881589010ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen F=C3=ADsico<label for=3D"m_1687355139881589010itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1687355139881589010ss-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%">
Al control de signos vitales:=20P/A: 120  69FC: 96T: 37.6Sat: 98Peso: 52 kilos ( refiere que ha bajado de peso)T: 1.62=20Piel: indemne, hidratadaCabeza: normocraneo, cabello implantadoAbdomen: distendidoEx superiores:  movilesEx inferiores: moviles, musculatura disminuida, pulsos (+), edema (-)</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-item-required m_1687355139881589010ss-text" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_1690694733">
<div class=3D"m_1687355139881589010ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_1687355139881589010itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1687355139881589010ss-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 cervicouterino</div>
</div>
</div>
</div>
<br>
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<div class=3D"m_1687355139881589010ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_1687355139881589010itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1687355139881589010ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
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<div class=3D"m_1687355139881589010ss-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%">
1.- Control en 4 dias2.- Refuerzo farmacologico3.- Refuerzo escala del dolor</div>
</div>
</div>
</div>
<br>
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<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-paragraph-text" style=3D"margin:12px 0">
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<div class=3D"m_1687355139881589010ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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1.- Clonazepam 2 mg un comprimido en la noche2.- Atorvastatina una en la noche3.-Ciruelax SOS4.- Esciralopram 1/2 dia5.-Fluconazol 150 mg una capsula al desayuno por semana durante 3 meses6.-Tramavolta 1/2- 1/2 - 1 de uso permanente7.- Dropol (paracetamol 1gr) 1 cada 8 horas x 3 dias8.- Norspam 5 mcg/hora Buprenorfina 1 parche con cambio en 5 dias9.- Macrosan, nitrofurantoina macrocristales 100mg 1 cada 8 horas por 10 dias10.- Detrucalm 200 mg 1 cada 8 horas x 5 dias</div>
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Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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<div class=3D"m_1687355139881589010ss-q-date">
<div class=3D"m_1687355139881589010ss-datetime-box m_1687355139881589010goog-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=C3=ADa</option>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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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>
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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>
 <option value=3D"25">
25</option>
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26</option>
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27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29" selected>
29</option>
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30</option>
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31</option>
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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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octubre</option>
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noviembre</option>
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diciembre</option>
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A=C3=B1o</option>
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1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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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>
 <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>
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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_1687355139881589010ss-form-question m_1687355139881589010errorbox-good">
<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-text" style=3D"margin:12px 0">
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<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_74766472">
<div class=3D"m_1687355139881589010ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_1687355139881589010ss-q-help m_1687355139881589010ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1687355139881589010ss-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>
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<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1687355139881589010ss-q-item-label" for=3D"m_1687355139881589010entry_1219705969">
<div class=3D"m_1687355139881589010ss-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_1687355139881589010ss-q-help m_1687355139881589010ss-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_1687355139881589010ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
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<label>
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<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"ENFERMERA" id=3D"m_1687355139881589010group_503039759_1" class=3D"m_1687355139881589010ss-q-checkbox">
</span>
<span class=3D"m_1687355139881589010ss-choice-label">
ENFERMERA</span>
</label>
</li>
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<label>
<span class=3D"m_1687355139881589010ss-choice-item-control m_1687355139881589010goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_1687355139881589010group_503039759_2" class=3D"m_1687355139881589010ss-q-checkbox">
</span>
<span class=3D"m_1687355139881589010ss-choice-label">
TENS</span>
</label>
</li>
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<label>
<span class=3D"m_1687355139881589010ss-choice-item-control m_1687355139881589010goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id==3D"m_1687355139881589010group_503039759_3" class=3D"m_1687355139881589010ss-q-checkbox">
</span>
<span class=3D"m_1687355139881589010ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
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<label>
<span class=3D"m_1687355139881589010ss-choice-item-control m_1687355139881589010goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"KINESIOLOGO" id=3D"m_1687355139881589010group_503039759_4" class=3D"m_1687355139881589010ss-q-checkbox">
</span>
<span class=3D"m_1687355139881589010ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
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<label>
<span class=3D"m_1687355139881589010ss-choice-item-control m_1687355139881589010goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"PSICOLOGO" id=3D"m_1687355139881589010group_503039759_5" class=3D"m_1687355139881589010ss-q-checkbox">
</span>
<span class=3D"m_1687355139881589010ss-choice-label">
PSICOLOGO</span>
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</li>
</ul>
</div>
</div>
</div>
<br>
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<div dir=3D"auto" class=3D"m_1687355139881589010ss-item m_1687355139881589010ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_1687355139881589010ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1687355139881589010ss-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_1687355139881589010ss-image" title=3D"" src=3D"https://lh5.googleusercontent.com/Bpur5zPteyG-bXtM-WNRuiLwTi8myvetX7lBkdjzbnQyqUlGcuv84zmWyU3x0Ua2-_WXX9PiJ2cMBOO0zhG2nHX7tXXPHH6_X8UTG8MZzIBwxETkF0a8JyZtuxSL" 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" rel=3D"noreferrer">
Crea tu propio formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
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