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Sandra Maulen Angel EU</div>
<div dir=3D"ltr">
<br>
Inicio del mensaje re=enviado:<br>
<br>
</div>
<blockquote type=3D"cite">
<div dir=3D"ltr">
<b>
De:</b>
 =Formularios de Google &lt;<a href=3D"mailto:forms-receipts-noreply@google.co=m">
forms-receipts-noreply@google.com</a>
&gt;<br>
<b>
Fecha:</b>
 18 de marzo de= 2019, 17:38:45 CLST<br>
<b>
Para:</b>
 <a href=3D"mailto:SANDRAMAULENANGEL@GMA=IL.COM">
SANDRAMAULENANGEL@GMAIL.COM</a>
<br>
<b>
Asunto:</b>
 <b>
Registro de Ate=nci=C3=B3n Domiciliaria Oncovida</b>
<br>
<br>
</div>
</blockquote>
<blockquote t=ype=3D"cite">
<div dir=3D"ltr">
<table border=3D"0" cellpadding=3D"0" cellspac=ing=3D"0" style=3D"background-color:rgb(38,4,154);" width=3D"100%" role=3D"p=resentation">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left: 24px">
<im=g alt=3D"Formularios de Google" height=3D"26px" style=3D"display: inline-blo=ck; margin: 0; vertical-align: middle;" width=3D"143px" src=3D"https://www.g=static.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbo=dy>
</table>
<div style=3D"padding: 24px; background-color:rgb(229,218,254)">
<=div align=3D"center" style=3D"background-color: #fff; border-bottom: 1px sol=id #e0e0e0; margin: 0 auto; max-width: 624px; min-width: 154px; padding: 0 2=4px;">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"b=ackground-color: #fff;" width=3D"100%" role=3D"presentation">
<tbody>
<tr heig=ht=3D"24px">
<td>
</td>
</tr>
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<div style=3D"font-size: 13px; line-height=: 18px; color: #424242; font-weight: 700">
Gracias por rellenar <a href=3D"ht=tps://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCV=v7UFdpPco75w/viewform?usp=3Dmail_form_link">
Registro de Atenci=C3=B3n Domici=liaria Oncovida</a>
</div>
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<tr height=3D"12px">
</tr>
<tr>
<td>
<div sty=le=3D"font-size: 13px; line-height: 18px; color: #424242;">
Esto es lo que no=s has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"ss-form-container" style==3D"">
<div class=3D"ss-form-heading" style=3D"">
<h1 class=3D"ss-form-title" d=ir=3D"ltr" style=3D"margin:.67em 0;">
Registro de Atenci=C3=B3n Domiciliaria O=ncovida</h1>
<div class=3D"ss-form-desc ss-no-ignore-whitespace" style=3D"font:inherit;wi=dth:99%;margin:0 0 1em;white-space:pre-wrap;word-wrap:break-word;">
Este es e=l sistema de registro de atenciones domiciliarias de Oncovida.   Debe ser ll=enado por el prestador individual, y debe realizarse un registro por cada vi=sita 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"ss-form" style=3D"">
<form action=3D"" method=3D"GET" id=3D"ss-=form" style=3D"">
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical=-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss=-q-item-label" for=3D"emailAddress" style=3D"">
<div class=3D"ss-q-title" sty=le=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
=Direcci=C3=B3n de correo electr=C3=B3nico<label for=3D"emailAddress" aria-label=3D"(Campo obligatorio)" style=3D"">
</=label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
</label>
<div class=3D"ss-q-text ss-printable-text-line" dir=3D"auto" style=3D"backgr=ound-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-spa=ce:pre-wrap;color:#545454;width:70%;">
<a href=3D"mailto:SANDRAMAULENANGEL@GM=AIL.COM">
SANDRAMAULENANGEL@GMAIL.COM</a>
</div>
</div>
</div>
</div>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style=3D="margin:12px 0;max-width:100%;position:relative;">
<div class=3D"ss-form-entr=y" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-t=op:0;max-width:100%;">
<h2 class=3D"ss-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"ss-image" title=3D"" src=3D"=https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGh=VlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width: 78px;outline:none;" alt=3D="Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0;">
=<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:mid=dle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class=3D"ss-page-title" style=3D"margin:2em -0.4em 0;padding:0.4em;backg=round-color:#eee;">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" dir=3D"auto" styl=e=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"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical=-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_579114469" style=3D"">
<div cla=ss=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;m=argin-bottom:.83em;">
Primer Nombre y Apellido Paterno<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
SANDRA MAULEN </div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical=-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_1276273985" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
RUT<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
RUT con Gui=C3=B3n y D=C3=ADgito Verif=icador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
16621429-7</div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-select" style=3D"marg=in:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertic=al-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_133691676" style=3D"">
<div cla=ss=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;m=argin-bottom:.83em;">
Tipo<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
Si asisten m=C3=A1s de 1 prestador sim=ult=C3=A1neamente, cada uno debe hacer un registro independiente</div>
</labe=l>
<select name=3D"entry.133691676" disabled=3D"" id=3D"entry_133691676" aria-l=abel=3D"Tipo Si asisten m=C3=A1s de 1 prestador simult=C3=A1neamente, cada u=no debe hacer un registro independiente " aria-required=3D"true" style=3D"">
=<option value=3D"" style=3D"">
</option>
<option value=3D"MEDICO" disabled=3D"" style=3D"">
MEDICO</option>
 <option va=lue=3D"ENFERMERA/O" disabled=3D"" selected=3D"" style=3D"">
ENFERMERA/O</opti=on>
 <option value=3D"TENS" disabled=3D"" style=3D"">
TENS</option>
 <option va=lue=3D"KINESIOLOGA/O" disabled=3D"" style=3D"">
KINESIOLOGA/O</option>
 <optio=n value=3D"PSICOLOGO" disabled=3D"" style=3D"">
PSICOLOGO</option>
 <option va=lue=3D"NUTRICIONISTA" disabled=3D"" style=3D"">
NUTRICIONISTA</option>
</selec=t>
</div>
</div>
</div>
<br>
 <div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style=3D="margin:12px 0;max-width:100%;position:relative;">
<div class=3D"ss-form-entr=y" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-t=op:0;max-width:100%;">
<h2 class=3D"ss-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"ss-image" title=3D"" src=3D"=https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lS=Ci4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width: 78px;outline:none;" alt=3D="Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0;">
=<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:mid=dle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class=3D"ss-page-title" style=3D"margin:2em -0.4em 0;padding:0.4em;backg=round-color:#eee;">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" dir=3D"auto" styl=e=3D"white-space:pre-wrap;word-wrap:break-word;">
En esta secci=C3=B3n debe i=ngresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
 <div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-section-header" style=3D"margin:12px 0=;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:=middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class=3D"ss-section-title" style=3D"background-color:#eee;padding:0.4em;=margin:2em -0.4em 0;">
Datos Personales del Paciente</h2>
<div class=3D"ss-section-description ss-no-ignore-whitespace" style=3D"margi=n-top:0.5em;white-space:pre-wrap;word-wrap:break-word;">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical=-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_823811303" style=3D"">
<div cla=ss=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;m=argin-bottom:.83em;">
Ingrese el Rut del Paciente<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
RUT con Gui=C3=B3n y D=C3=ADgito Verif=icador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
5632200-K</div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical=-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_1959365839" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Ingrese el Primer Nombre y Apellido Paterno del Pacien=te<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
MARIA SABOGAL</div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-select" style=3D"marg=in:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertic=al-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_545002227" style=3D"">
<div cla=ss=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;m=argin-bottom:.83em;">
Previsi=C3=B3n<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<select name=3D"entry.545002227" disabled=3D"" id=3D"entry_545002227" aria-l=abel=3D"Previsi=C3=B3n  " aria-required=3D"true" style=3D"">
<option value=3D="" style=3D"">
</option>
<option value=3D"BANMEDICA" disabled=3D"" style=3D"">
BANMEDICA</option>
 <opt=ion value=3D"CAPREDENA" disabled=3D"" style=3D"">
CAPREDENA</option>
 <option v=alue=3D"COLMENA" disabled=3D"" style=3D"">
COLMENA</option>
 <option value=3D"=CONSALUD" disabled=3D"" selected=3D"" style=3D"">
CONSALUD</option>
 <option v=alue=3D"CRUZ BLANCA" disabled=3D"" style=3D"">
CRUZ BLANCA</option>
 <option v=alue=3D"DIPRECA" disabled=3D"" style=3D"">
DIPRECA</option>
 <option value=3D"=FONASA" disabled=3D"" style=3D"">
FONASA</option>
 <option value=3D"FUNDACION"= disabled=3D"" style=3D"">
FUNDACION</option>
 <option value=3D"ISAPRES DEL CO=BRE" disabled=3D"" style=3D"">
ISAPRES DEL COBRE</option>
 <option value=3D"NU=EVA MASVIDA" disabled=3D"" style=3D"">
NUEVA MASVIDA</option>
 <option value=3D="VIDATRES" disabled=3D"" style=3D"">
VIDATRES</option>
 <option value=3D"PARTI=CULAR" disabled=3D"" style=3D"">
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical=-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_1900161356" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Ciudad<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
OLMUE </div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical=-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_1298871758" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Comuna<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
OLMUE</div>
</div>
</div>
</div>
<br>
 <div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style=3D="margin:12px 0;max-width:100%;position:relative;">
<div class=3D"ss-form-entr=y" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-t=op:0;max-width:100%;">
<h2 class=3D"ss-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"ss-image" title=3D"" src=3D"=https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn=1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width: 78px;outline:none;" alt=3D="Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0;">
=<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:mid=dle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class=3D"ss-page-title" style=3D"margin:2em -0.4em 0;padding:0.4em;backg=round-color:#eee;">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" dir=3D"auto" styl=e=3D"white-space:pre-wrap;word-wrap:break-word;">
En esta secci=C3=B3n debe i=ngresar los datos de la atenci=C3=B3n domiciliaria</div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-radio" style=3D"margi=n:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertica=l-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_2073233714" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Tipo de Atenci=C3=B3n<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<ul class=3D"ss-choices" role=3D"radiogroup" aria-label=3D"Tipo de Atenci=C3==B3n  " style=3D"list-style:none;padding:0;margin:.5em 0 0;">
<li class=3D"ss=-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em;">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"pos=ition:relative;display:inline-block;">
<input type=3D"radio" name=3D"entry.12=22378237" disabled=3D"" value=3D"Domicilio" id=3D"group_1222378237_1" role=3D="radio" class=3D"ss-q-radio" aria-label=3D"Domicilio" aria-required=3D"true"= style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
Domicilio</span>
</label>
</li>
 <li class=3D"ss-choice-item" style=3D"margin:0;line-height:1.3=em;padding-bottom:.5em;">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"pos=ition:relative;display:inline-block;">
<input type=3D"radio" name=3D"entry.12=22378237" disabled=3D"" checked=3D"" value=3D"Ambulatorio" id=3D"group_12223=78237_2" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"Ambulatorio" aria=-required=3D"true" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-date" style=3D"margin=:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical=-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_1705849412" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Fecha de la Atenci=C3=B3n<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"ss-q-date" role=3D"group" aria-label=3D"Fecha de la Atenci=C3=B3=n  " style=3D"">
<div class=3D"ss-datetime-box goog-inline-block" role=3D"gro=up" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;paddi=ng-left:3px;vertical-align:middle;margin:4px 3px;position:relative;display:i=nline-block;">
 <select name=3D"entry.1705849412_day" disabled=3D"" class=3D"=ss-day-dropdown" id=3D"entry.1705849412_day" aria-label=3D"D=C3=ADa del mes"= aria-required=3D"true" style=3D"">
<option value=3D"" style=3D"">
D=C3=ADa</o=ption>
<option value=3D"1" style=3D"">
1</option>
 <option value=3D"2" style=3D"">
2</=option>
 <option value=3D"3" style=3D"">
3</option>
 <option value=3D"4" style=3D="">
4</option>
 <option value=3D"5" style=3D"">
5</option>
 <option value=3D"6" s=tyle=3D"">
6</option>
 <option value=3D"7" style=3D"">
7</option>
 <option value==3D"8" style=3D"">
8</option>
 <option value=3D"9" style=3D"">
9</option>
 <opti=on value=3D"10" style=3D"">
10</option>
 <option value=3D"11" style=3D"">
11</o=ption>
 <option value=3D"12" selected=3D"" style=3D"">
12</option>
 <option val=ue=3D"13" style=3D"">
13</option>
 <option value=3D"14" style=3D"">
14</option>
= <option value=3D"15" style=3D"">
15</option>
 <option value=3D"16" style=3D""=>
16</option>
 <option value=3D"17" style=3D"">
17</option>
 <option value=3D"18=" style=3D"">
18</option>
 <option value=3D"19" style=3D"">
19</option>
 <option= value=3D"20" style=3D"">
20</option>
 <option value=3D"21" style=3D"">
21</opt=ion>
 <option value=3D"22" style=3D"">
22</option>
 <option value=3D"23" style=3D="">
23</option>
 <option value=3D"24" style=3D"">
24</option>
 <option value=3D"=25" style=3D"">
25</option>
 <option value=3D"26" style=3D"">
26</option>
 <opti=on value=3D"27" style=3D"">
27</option>
 <option value=3D"28" style=3D"">
28</o=ption>
 <option value=3D"29" style=3D"">
29</option>
 <option value=3D"30" styl=e=3D"">
30</option>
 <option value=3D"31" style=3D"">
31</option>
</select>
   <s=elect name=3D"entry.1705849412_month" disabled=3D"" class=3D"ss-month-dropdo=wn" id=3D"entry.1705849412_month" aria-label=3D"Mes" aria-required=3D"true" s=tyle=3D"">
<option value=3D"" style=3D"">
Mes</option>
<option value=3D"1" style=3D"">
enero</option>
 <option value=3D"2" style=3D""=>
febrero</option>
 <option value=3D"3" selected=3D"" style=3D"">
marzo</option=>
 <option value=3D"4" style=3D"">
abril</option>
 <option value=3D"5" style=3D="">
mayo</option>
 <option value=3D"6" style=3D"">
junio</option>
 <option value==3D"7" style=3D"">
julio</option>
 <option value=3D"8" style=3D"">
agosto</opti=on>
 <option value=3D"9" style=3D"">
septiembre</option>
 <option value=3D"10" s=tyle=3D"">
octubre</option>
 <option value=3D"11" style=3D"">
noviembre</option=>
 <option value=3D"12" style=3D"">
diciembre</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled=3D"" id=3D"entry.1705849412_=year" aria-label=3D"A=C3=B1o" aria-required=3D"true" style=3D"">
<option valu=e=3D"" style=3D"">
A=C3=B1o</option>
<option value=3D"1896" style=3D"">
1896</option>
 <option value=3D"1897" style==3D"">
1897</option>
 <option value=3D"1898" style=3D"">
1898</option>
 <option v=alue=3D"1899" style=3D"">
1899</option>
 <option value=3D"1900" style=3D"">
190=0</option>
 <option value=3D"1901" style=3D"">
1901</option>
 <option value=3D"=1902" style=3D"">
1902</option>
 <option value=3D"1903" style=3D"">
1903</optio=n>
 <option value=3D"1904" style=3D"">
1904</option>
 <option value=3D"1905" st=yle=3D"">
1905</option>
 <option value=3D"1906" style=3D"">
1906</option>
 <opti=on value=3D"1907" style=3D"">
1907</option>
 <option value=3D"1908" style=3D""=>
1908</option>
 <option value=3D"1909" style=3D"">
1909</option>
 <option value==3D"1910" style=3D"">
1910</option>
 <option value=3D"1911" style=3D"">
1911</o=ption>
 <option value=3D"1912" style=3D"">
1912</option>
 <option value=3D"1913=" style=3D"">
1913</option>
 <option value=3D"1914" style=3D"">
1914</option>
 <=option value=3D"1915" style=3D"">
1915</option>
 <option value=3D"1916" style=3D="">
1916</option>
 <option value=3D"1917" style=3D"">
1917</option>
 <option val=ue=3D"1918" style=3D"">
1918</option>
 <option value=3D"1919" style=3D"">
1919<=/option>
 <option value=3D"1920" style=3D"">
1920</option>
 <option value=3D"19=21" style=3D"">
1921</option>
 <option value=3D"1922" style=3D"">
1922</option>
= <option value=3D"1923" style=3D"">
1923</option>
 <option value=3D"1924" styl=e=3D"">
1924</option>
 <option value=3D"1925" style=3D"">
1925</option>
 <option= value=3D"1926" style=3D"">
1926</option>
 <option value=3D"1927" style=3D"">
1=927</option>
 <option value=3D"1928" style=3D"">
1928</option>
 <option value=3D="1929" style=3D"">
1929</option>
 <option value=3D"1930" style=3D"">
1930</opti=on>
 <option value=3D"1931" style=3D"">
1931</option>
 <option value=3D"1932" s=tyle=3D"">
1932</option>
 <option value=3D"1933" style=3D"">
1933</option>
 <opt=ion value=3D"1934" style=3D"">
1934</option>
 <option value=3D"1935" style=3D"=">
1935</option>
 <option value=3D"1936" style=3D"">
1936</option>
 <option valu=e=3D"1937" style=3D"">
1937</option>
 <option value=3D"1938" style=3D"">
1938</=option>
 <option value=3D"1939" style=3D"">
1939</option>
 <option value=3D"194=0" style=3D"">
1940</option>
 <option value=3D"1941" style=3D"">
1941</option>
 <=option value=3D"1942" style=3D"">
1942</option>
 <option value=3D"1943" style=3D="">
1943</option>
 <option value=3D"1944" style=3D"">
1944</option>
 <option val=ue=3D"1945" style=3D"">
1945</option>
 <option value=3D"1946" style=3D"">
1946<=/option>
 <option value=3D"1947" style=3D"">
1947</option>
 <option value=3D"19=48" style=3D"">
1948</option>
 <option value=3D"1949" style=3D"">
1949</option>
= <option value=3D"1950" style=3D"">
1950</option>
 <option value=3D"1951" styl=e=3D"">
1951</option>
 <option value=3D"1952" style=3D"">
1952</option>
 <option= value=3D"1953" style=3D"">
1953</option>
 <option value=3D"1954" style=3D"">
1=954</option>
 <option value=3D"1955" style=3D"">
1955</option>
 <option value=3D="1956" style=3D"">
1956</option>
 <option value=3D"1957" style=3D"">
1957</opti=on>
 <option value=3D"1958" style=3D"">
1958</option>
 <option value=3D"1959" s=tyle=3D"">
1959</option>
 <option value=3D"1960" style=3D"">
1960</option>
 <opt=ion value=3D"1961" style=3D"">
1961</option>
 <option value=3D"1962" style=3D"=">
1962</option>
 <option value=3D"1963" style=3D"">
1963</option>
 <option valu=e=3D"1964" style=3D"">
1964</option>
 <option value=3D"1965" style=3D"">
1965</=option>
 <option value=3D"1966" style=3D"">
1966</option>
 <option value=3D"196=7" style=3D"">
1967</option>
 <option value=3D"1968" style=3D"">
1968</option>
 <=option value=3D"1969" style=3D"">
1969</option>
 <option value=3D"1970" style=3D="">
1970</option>
 <option value=3D"1971" style=3D"">
1971</option>
 <option val=ue=3D"1972" style=3D"">
1972</option>
 <option value=3D"1973" style=3D"">
1973<=/option>
 <option value=3D"1974" style=3D"">
1974</option>
 <option value=3D"19=75" style=3D"">
1975</option>
 <option value=3D"1976" style=3D"">
1976</option>
= <option value=3D"1977" style=3D"">
1977</option>
 <option value=3D"1978" styl=e=3D"">
1978</option>
 <option value=3D"1979" style=3D"">
1979</option>
 <option= value=3D"1980" style=3D"">
1980</option>
 <option value=3D"1981" style=3D"">
1=981</option>
 <option value=3D"1982" style=3D"">
1982</option>
 <option value=3D="1983" style=3D"">
1983</option>
 <option value=3D"1984" style=3D"">
1984</opti=on>
 <option value=3D"1985" style=3D"">
1985</option>
 <option value=3D"1986" s=tyle=3D"">
1986</option>
 <option value=3D"1987" style=3D"">
1987</option>
 <opt=ion value=3D"1988" style=3D"">
1988</option>
 <option value=3D"1989" style=3D"=">
1989</option>
 <option value=3D"1990" style=3D"">
1990</option>
 <option valu=e=3D"1991" style=3D"">
1991</option>
 <option value=3D"1992" style=3D"">
1992</=option>
 <option value=3D"1993" style=3D"">
1993</option>
 <option value=3D"199=4" style=3D"">
1994</option>
 <option value=3D"1995" style=3D"">
1995</option>
 <=option value=3D"1996" style=3D"">
1996</option>
 <option value=3D"1997" style=3D="">
1997</option>
 <option value=3D"1998" style=3D"">
1998</option>
 <option val=ue=3D"1999" style=3D"">
1999</option>
 <option value=3D"2000" style=3D"">
2000<=/option>
 <option value=3D"2001" style=3D"">
2001</option>
 <option value=3D"20=02" style=3D"">
2002</option>
 <option value=3D"2003" style=3D"">
2003</option>
= <option value=3D"2004" style=3D"">
2004</option>
 <option value=3D"2005" styl=e=3D"">
2005</option>
 <option value=3D"2006" style=3D"">
2006</option>
 <option= value=3D"2007" style=3D"">
2007</option>
 <option value=3D"2008" style=3D"">
2=008</option>
 <option value=3D"2009" style=3D"">
2009</option>
 <option value=3D="2010" style=3D"">
2010</option>
 <option value=3D"2011" style=3D"">
2011</opti=on>
 <option value=3D"2012" style=3D"">
2012</option>
 <option value=3D"2013" s=tyle=3D"">
2013</option>
 <option value=3D"2014" style=3D"">
2014</option>
 <opt=ion value=3D"2015" style=3D"">
2015</option>
 <option value=3D"2016" style=3D"=">
2016</option>
 <option value=3D"2017" style=3D"">
2017</option>
 <option valu=e=3D"2018" style=3D"">
2018</option>
 <option value=3D"2019" selected=3D"" sty=le=3D"">
2019</option>
 <option value=3D"2020" style=3D"">
2020</option>
 <optio=n value=3D"2021" style=3D"">
2021</option>
 <option value=3D"2022" style=3D"">
=2022</option>
 <option value=3D"2023" style=3D"">
2023</option>
 <option value=3D="2024" style=3D"">
2024</option>
 <option value=3D"2025" style=3D"">
2025</opti=on>
 <option value=3D"2026" style=3D"">
2026</option>
 <option value=3D"2027" s=tyle=3D"">
2027</option>
 <option value=3D"2028" style=3D"">
2028</option>
 <opt=ion value=3D"2029" style=3D"">
2029</option>
 <option value=3D"2030" style=3D"=">
2030</option>
 <option value=3D"2031" style=3D"">
2031</option>
 <option valu=e=3D"2032" style=3D"">
2032</option>
 <option value=3D"2033" style=3D"">
2033</=option>
 <option value=3D"2034" style=3D"">
2034</option>
 <option value=3D"203=5" style=3D"">
2035</option>
 <option value=3D"2036" style=3D"">
2036</option>
 <=option value=3D"2037" style=3D"">
2037</option>
 <option value=3D"2038" style=3D="">
2038</option>
 <option value=3D"2039" style=3D"">
2039</option>
 <option val=ue=3D"2040" style=3D"">
2040</option>
 <option value=3D"2041" style=3D"">
2041<=/option>
 <option value=3D"2042" style=3D"">
2042</option>
 <option value=3D"20=43" style=3D"">
2043</option>
 <option value=3D"2044" style=3D"">
2044</option>
= <option value=3D"2045" style=3D"">
2045</option>
 <option value=3D"2046" styl=e=3D"">
2046</option>
 <option value=3D"2047" style=3D"">
2047</option>
 <option= value=3D"2048" style=3D"">
2048</option>
 <option value=3D"2049" style=3D"">
2=049</option>
 <option value=3D"2050" style=3D"">
2050</option>
 <option value=3D="2051" style=3D"">
2051</option>
 <option value=3D"2052" style=3D"">
2052</opti=on>
 <option value=3D"2053" style=3D"">
2053</option>
 <option value=3D"2054" s=tyle=3D"">
2054</option>
 <option value=3D"2055" style=3D"">
2055</option>
 <opt=ion value=3D"2056" style=3D"">
2056</option>
 <option value=3D"2057" style=3D"=">
2057</option>
 <option value=3D"2058" style=3D"">
2058</option>
 <option valu=e=3D"2059" style=3D"">
2059</option>
 <option value=3D"2060" style=3D"">
2060</=option>
 <option value=3D"2061" style=3D"">
2061</option>
 <option value=3D"206=2" style=3D"">
2062</option>
 <option value=3D"2063" style=3D"">
2063</option>
 <=option value=3D"2064" style=3D"">
2064</option>
 <option value=3D"2065" style=3D="">
2065</option>
 <option value=3D"2066" style=3D"">
2066</option>
 <option val=ue=3D"2067" style=3D"">
2067</option>
 <option value=3D"2068" style=3D"">
2068<=/option>
 <option value=3D"2069" style=3D"">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-time" style=3D"margin=:12px 0;font:inherit;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1=.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_206244955" style=3D"">
<div cla=ss=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;m=argin-bottom:.83em;">
Hora de la Atenci=C3=B3n<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
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4</label>
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5</label>
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8</l=abel>
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10</label>
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<div aria-hidde=n=3D"true" class=3D"aria-todo" style=3D"">
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<div class=3D"ss-scale=row-fieldcell" style=3D"">
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<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
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<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
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<label class=3D="ss-scalenumber" for=3D"group_1244707512_4" style=3D"display:block;padding:0=.5em 0 .5em;">
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4</label>
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7</label>
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<label class=3D"ss-scalenumber" f=or=3D"group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em;">
8</l=abel>
</td>
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</td>
 <td class=3D"ss-scalenumbers" style=3D="text-align:center;">
<label class=3D"ss-scalenumber" for=3D"group_1244707512=_11" style=3D"display:block;padding:0.5em 0 .5em;">
10</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center;">
</td>
</tr>
<tr role=3D"radiogroup" aria-label=3D"Escala Dolor EVA M=C3=A1ximo  Seleccio=na un valor en el intervalo de 0 a 10 ." style=3D"">
<td class=3D"ss-scalerow= ss-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 aria-=hidden=3D"true" class=3D"aria-todo" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center;color:#666;border:1px s=olid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class=3D="ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entry.12447=07512" disabled=3D"" checked=3D"" value=3D"0" id=3D"group_1244707512_1" role==3D"radio" class=3D"ss-q-radio" aria-label=3D"0" style=3D"">
</div>
</td>
 <td c=lass=3D"ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #=d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class=3D"ss-sc=alerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entry.1244707512"= disabled=3D"" value=3D"1" id=3D"group_1244707512_2" role=3D"radio" class=3D="ss-q-radio" aria-label=3D"1" style=3D"">
</div>
</td>
 <td class=3D"ss-scalero=w" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-lef=t:0;border-right:0;padding:.5em .25em;">
<div class=3D"ss-scalerow-fieldcell"= style=3D"">
<input type=3D"radio" name=3D"entry.1244707512" disabled=3D"" va=lue=3D"2" id=3D"group_1244707512_3" role=3D"radio" class=3D"ss-q-radio" aria=-label=3D"2" style=3D"">
</div>
</td>
 <td class=3D"ss-scalerow" style=3D"text-=align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:=0;padding:.5em .25em;">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<inpu=t type=3D"radio" name=3D"entry.1244707512" disabled=3D"" value=3D"3" id=3D"g=roup_1244707512_4" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"3" styl=e=3D"">
</div>
</td>
 <td class=3D"ss-scalerow" style=3D"text-align:center;colo=r:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .2=5em;">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" n=ame=3D"entry.1244707512" disabled=3D"" value=3D"4" id=3D"group_1244707512_5"= role=3D"radio" class=3D"ss-q-radio" aria-label=3D"4" style=3D"">
</div>
</td>
= <td class=3D"ss-scalerow" style=3D"text-align:center;color:#666;border:1px s=olid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class=3D="ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entry.12447=07512" disabled=3D"" value=3D"5" id=3D"group_1244707512_6" role=3D"radio" cl=ass=3D"ss-q-radio" aria-label=3D"5" style=3D"">
</div>
</td>
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<div class=3D"ss-scalerow-fiel=dcell" style=3D"">
<input type=3D"radio" name=3D"entry.1244707512" disabled=3D="" value=3D"6" id=3D"group_1244707512_7" role=3D"radio" class=3D"ss-q-radio"= aria-label=3D"6" style=3D"">
</div>
</td>
 <td class=3D"ss-scalerow" style=3D"=text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-r=ight:0;padding:.5em .25em;">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
=<input type=3D"radio" name=3D"entry.1244707512" disabled=3D"" value=3D"7" id==3D"group_1244707512_8" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"7"= style=3D"">
</div>
</td>
 <td class=3D"ss-scalerow" style=3D"text-align:center=;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5=em .25em;">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"ra=dio" name=3D"entry.1244707512" disabled=3D"" value=3D"8" id=3D"group_1244707=512_9" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"8" style=3D"">
</div=>
</td>
 <td class=3D"ss-scalerow" style=3D"text-align:center;color:#666;borde=r:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div c=lass=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entr=y.1244707512" disabled=3D"" value=3D"9" id=3D"group_1244707512_10" role=3D"r=adio" class=3D"ss-q-radio" aria-label=3D"9" style=3D"">
</div>
</td>
 <td class==3D"ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d=8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class=3D"ss-scale=row-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entry.1244707512" di=sabled=3D"" value=3D"10" id=3D"group_1244707512_11" role=3D"radio" class=3D"=ss-q-radio" aria-label=3D"10" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow ss-rightlabel" aria-hidden=3D"true" style=3D"text-a=lign:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;p=adding:.5em .25em;padding-right:0;">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item  ss-scale" style=3D"margin:12px 0;overflo=w-x:auto;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertica=l-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_2000523015" style=3D"">
<div cl=ass=3D"ss-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"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"entry_85311863=0" style=3D"">
<tbody>
<tr aria-hidden=3D"true" style=3D"">
<td class=3D"ss-sca=lenumbers" style=3D"text-align:center;">
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center;">
<label class=3D"s=s-scalenumber" for=3D"group_853118630_1" style=3D"display:block;padding:0.5e=m 0 .5em;">
0</label>
</td>
 <td class=3D"ss-scalenumbers" style=3D"text-align:=center;">
<label class=3D"ss-scalenumber" for=3D"group_853118630_2" style=3D"=display:block;padding:0.5em 0 .5em;">
1</label>
</td>
 <td class=3D"ss-scalenum=bers" style=3D"text-align:center;">
<label class=3D"ss-scalenumber" for=3D"gr=oup_853118630_3" style=3D"display:block;padding:0.5em 0 .5em;">
2</label>
</td=>
 <td class=3D"ss-scalenumbers" style=3D"text-align:center;">
<label class=3D="ss-scalenumber" for=3D"group_853118630_4" style=3D"display:block;padding:0.=5em 0 .5em;">
3</label>
</td>
 <td class=3D"ss-scalenumbers" style=3D"text-alig=n:center;">
<label class=3D"ss-scalenumber" for=3D"group_853118630_5" style=3D="display:block;padding:0.5em 0 .5em;">
4</label>
</td>
 <td class=3D"ss-scalenu=mbers" style=3D"text-align:center;">
<label class=3D"ss-scalenumber" for=3D"g=roup_853118630_6" style=3D"display:block;padding:0.5em 0 .5em;">
5</label>
</t=d>
 <td class=3D"ss-scalenumbers" style=3D"text-align:center;">
<label class=3D="ss-scalenumber" for=3D"group_853118630_7" style=3D"display:block;padding:0.=5em 0 .5em;">
6</label>
</td>
 <td class=3D"ss-scalenumbers" style=3D"text-alig=n:center;">
<label class=3D"ss-scalenumber" for=3D"group_853118630_8" style=3D="display:block;padding:0.5em 0 .5em;">
7</label>
</td>
 <td class=3D"ss-scalenu=mbers" style=3D"text-align:center;">
<label class=3D"ss-scalenumber" for=3D"g=roup_853118630_9" style=3D"display:block;padding:0.5em 0 .5em;">
8</label>
</t=d>
 <td class=3D"ss-scalenumbers" style=3D"text-align:center;">
<label class=3D="ss-scalenumber" for=3D"group_853118630_10" style=3D"display:block;padding:0=.5em 0 .5em;">
9</label>
</td>
 <td class=3D"ss-scalenumbers" style=3D"text-ali=gn:center;">
<label class=3D"ss-scalenumber" for=3D"group_853118630_11" style==3D"display:block;padding:0.5em 0 .5em;">
10</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center;">
</td>
</tr>
<tr role=3D"radiogroup" aria-label=3D"Escala Dolor EVA M=C3=ADnimo  Seleccio=na un valor en el intervalo de 0 a 10 ." style=3D"">
<td class=3D"ss-scalerow= ss-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 aria-=hidden=3D"true" class=3D"aria-todo" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center;color:#666;border:1px s=olid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class=3D="ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entry.85311=8630" disabled=3D"" checked=3D"" value=3D"0" id=3D"group_853118630_1" role=3D="radio" class=3D"ss-q-radio" aria-label=3D"0" style=3D"">
</div>
</td>
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<div class=3D"ss-sca=lerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entry.853118630" d=isabled=3D"" value=3D"1" id=3D"group_853118630_2" role=3D"radio" class=3D"ss=-q-radio" aria-label=3D"1" style=3D"">
</div>
</td>
 <td class=3D"ss-scalerow" s=tyle=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;=border-right:0;padding:.5em .25em;">
<div class=3D"ss-scalerow-fieldcell" sty=le=3D"">
<input type=3D"radio" name=3D"entry.853118630" disabled=3D"" value=3D="2" id=3D"group_853118630_3" role=3D"radio" class=3D"ss-q-radio" aria-label=3D="2" style=3D"">
</div>
</td>
 <td class=3D"ss-scalerow" style=3D"text-align:cen=ter;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding=:.5em .25em;">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D="radio" name=3D"entry.853118630" disabled=3D"" value=3D"3" id=3D"group_85311=8630_4" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"3" style=3D"">
</di=v>
</td>
 <td class=3D"ss-scalerow" style=3D"text-align:center;color:#666;bord=er:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div c=lass=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entr=y.853118630" disabled=3D"" value=3D"4" id=3D"group_853118630_5" role=3D"radi=o" class=3D"ss-q-radio" aria-label=3D"4" style=3D"">
</div>
</td>
 <td class=3D="ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3=;border-left:0;border-right:0;padding:.5em .25em;">
<div class=3D"ss-scalerow=-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entry.853118630" disabl=ed=3D"" value=3D"5" id=3D"group_853118630_6" role=3D"radio" class=3D"ss-q-ra=dio" aria-label=3D"5" style=3D"">
</div>
</td>
 <td class=3D"ss-scalerow" style==3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;bord=er-right:0;padding:.5em .25em;">
<div class=3D"ss-scalerow-fieldcell" style=3D="">
<input type=3D"radio" name=3D"entry.853118630" disabled=3D"" value=3D"6" i=d=3D"group_853118630_7" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"6"= style=3D"">
</div>
</td>
 <td class=3D"ss-scalerow" style=3D"text-align:center=;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5=em .25em;">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"ra=dio" name=3D"entry.853118630" disabled=3D"" value=3D"7" id=3D"group_85311863=0_8" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"7" style=3D"">
</div>
<=/td>
 <td class=3D"ss-scalerow" style=3D"text-align:center;color:#666;border:=1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div cla=ss=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entry.=853118630" disabled=3D"" value=3D"8" id=3D"group_853118630_9" role=3D"radio"= class=3D"ss-q-radio" aria-label=3D"8" style=3D"">
</div>
</td>
 <td class=3D"s=s-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;b=order-left:0;border-right:0;padding:.5em .25em;">
<div class=3D"ss-scalerow-f=ieldcell" style=3D"">
<input type=3D"radio" name=3D"entry.853118630" disabled==3D"" value=3D"9" id=3D"group_853118630_10" role=3D"radio" class=3D"ss-q-rad=io" aria-label=3D"9" style=3D"">
</div>
</td>
 <td class=3D"ss-scalerow" style=3D="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-=right:0;padding:.5em .25em;">
<div class=3D"ss-scalerow-fieldcell" style=3D""=>
<input type=3D"radio" name=3D"entry.853118630" disabled=3D"" value=3D"10" i=d=3D"group_853118630_11" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"1=0" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow ss-rightlabel" aria-hidden=3D"true" style=3D"text-a=lign:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;p=adding:.5em .25em;padding-right:0;">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
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<div dir=3D"auto" class=3D"ss-item ss-item-required ss-paragraph-text" style==3D"margin:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5e=m;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_2140974612" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Anamnesis/Evoluci=C3=B3n<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
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<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
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</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
PACIENTE CON REGULAR EVOLUCION UN POCO MAS ESTACIONARIA QUE L=A ULTIMA VISITA, CONTROL CON MEDICO ONCOLOGO SUGIERA LA POSIBILIDAD  DE TRAT=AMIENTO CON QUIMIO ORAL COMO TRTAMIENTO PALEATIVO NO CURATIVO.PACIENTE DE MEJOR ESTADO DE ANIMO CONCIENTE.SIN DOLOR NI MOLESTIAS POR TRATAMIENDO DE TRANSTEC.SE MANTIENE GRAN PARTE DEL TIEMPO ENCAMADA, VA AL BA=C3=91O CON AYUDA Y SE A=GOTA BASTANTE.REPOSO Y SUE=C3=91O BIEN TOLERADO POR ACTIVADOR DEL SUE=C3=91OALIMENTACION CADA VEZ MENOS TOLERABLE, TOLERA ALIMENTACION MAS SIN RESIDUOS O= MOLIDA.</div>
</div>
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</div>
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<label class=3D"ss-q-item-label" for=3D"entry_824006088" style=3D"">
<div cla=ss=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;m=argin-bottom:.83em;">
Examen F=C3=ADsico<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
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<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
PACIENTE CON HEMODINAMIA ESTABLE AFEBRIL NORMOTENSA 127/88 NO=RMOCARDICA 89X AFEBRIL SIN APREMIO VENTILAROIO SATURACION 94%.PIEL SANA AREA SACRA CON ENROJICIMIENTO, SE EDUCA EN CAMBIO DE POSICION SE A=CONSEJA COMPRA DE BIOCURE PARA LUBRICACION DE PIEL O LINOVERA.PACIENTE MUY DELGADA ULTIMO CONTROL CON NUTRICIONISTA PESANDO 40 KILOS.ABDOMEN DURO DISTENDIDO UN POCO, HIGADO CON INFLAMACION EN REGRESION.DIREUSIS NORMAL.DEPOSICIONES HACE DOS DIAS SIN DEPOS.</div>
</div>
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</div>
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<label class=3D"ss-q-item-label" for=3D"entry_1690694733" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Diagn=C3=B3stico<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
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<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
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<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
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</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
CA DE COLON METASTASICO</div>
</div>
</div>
</div>
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<label class=3D"ss-q-item-label" for=3D"entry_1255665248" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Plan de Tratamiento e Indicaciones<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
- CONTENCION EMOCIONAL CON PARTE DEL GRUPO FAMILIAR SOBRE TOD=O CON LAS HIJAS.- MANEJO DEL DOLOR.- HIDRATACION POR BOCA LO MAS QUE PUEDA.- EVALUACION DE SUBCUTANEO EN PROX VISITA.- CONTROL CON EL RESTO DEL EQUIPO KINESIOLOGO Y NUTRICIONISTA.=20</div>
</div>
</div>
</div>
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<label class=3D"ss-q-item-label" for=3D"entry_1648939075" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Medicamentos Indicados</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
- 1/2 TRANSTEC CADA 72 HORAS</div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item  ss-date" style=3D"margin:12px 0;">
<div c=lass=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;ma=rgin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_2063615873" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
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<div class=3D"ss-q-date" role=3D"group" aria-label=3D"Fecha aproximada del P=r=C3=B3ximo Control con usted  " style=3D"">
<div class=3D"ss-datetime-box go=og-inline-block" role=3D"group" style=3D"border:1px solid #dcdcdc;margin-rig=ht:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px=;position:relative;display:inline-block;">
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<option value=3D"" style=3D"">
D=C3=AD=a</option>
<option value=3D"1" style=3D"">
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</o=ption>
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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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1=8</option>
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19</option>
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20</option>
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21</opti=on>
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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</o=ption>
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29</option>
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31</option>
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Mes</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</opti=on>
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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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<option value=3D"" style=3D"">
A=C3=B1=o</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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190=0</option>
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1901</option>
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1902</option>
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1903</optio=n>
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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</o=ption>
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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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1=927</option>
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1928</option>
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1929</option>
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1930</opti=on>
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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>
= <option value=3D"1950" style=3D"">
1950</option>
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1951</option>
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1952</option>
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1953</option>
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1=954</option>
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1955</option>
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1956</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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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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1=981</option>
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1982</option>
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1983</option>
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1984</opti=on>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</=option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000<=/option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2=008</option>
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2009</option>
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2010</option>
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2011</opti=on>
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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>
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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</opti=on>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
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2032</option>
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2033</=option>
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2034</option>
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2035</option>
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2036</option>
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2037</option>
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2038</option>
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2039</option>
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2040</option>
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2041<=/option>
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2042</option>
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2043</option>
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2044</option>
= <option value=3D"2045" style=3D"">
2045</option>
 <option value=3D"2046" styl=e=3D"">
2046</option>
 <option value=3D"2047" style=3D"">
2047</option>
 <option= value=3D"2048" style=3D"">
2048</option>
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2=049</option>
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2050</option>
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2051</option>
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2052</opti=on>
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2053</option>
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2054</option>
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2055</option>
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2056</option>
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2057</option>
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2058</option>
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2059</option>
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2060</=option>
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2061</option>
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2062</option>
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2063</option>
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2064</option>
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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>
</select>
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<br>
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<div dir=3D"auto" class=3D"ss-item  ss-text" style=3D"margin:12px 0;">
<div c=lass=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;ma=rgin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_74766472" style=3D"">
<div clas=s=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;ma=rgin-bottom:.83em;">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item  ss-checkbox" style=3D"margin:12px 0;">
<d=iv class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middl=e;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_1219705969" style=3D"">
<div cl=ass=3D"ss-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"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
S=C3=B3lo llene esta secci=C3=B3n si e=s m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
</label=>
<ul class=3D"ss-choices" role=3D"group" aria-label=3D"Derivaci=C3=B3n a otro= Prestador Domiciliario S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y= solicita la visita de otro prestador del equipo " style=3D"list-style:none;=padding:0;margin:.5em 0 0;">
<li class=3D"ss-choice-item" style=3D"margin:0;l=ine-height:1.3em;padding-bottom:.5em;">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"pos=ition:relative;display:inline-block;">
<input type=3D"checkbox" name=3D"entry=.503039759" disabled=3D"" value=3D"ENFERMERA" id=3D"group_503039759_1" role=3D="checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
ENFERMERA</span>
</label>
</li>
 <li class=3D"ss-choice-item" style=3D"margin:0;line-height:1.3=em;padding-bottom:.5em;">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"pos=ition:relative;display:inline-block;">
<input type=3D"checkbox" name=3D"entry=.503039759" disabled=3D"" value=3D"TENS" id=3D"group_503039759_2" role=3D"ch=eckbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
TENS</span>
</label>
</li>
 <li class=3D"ss-choice-item" style=3D"margin:0;line-height:1.3=em;padding-bottom:.5em;">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"pos=ition:relative;display:inline-block;">
<input type=3D"checkbox" name=3D"entry=.503039759" disabled=3D"" value=3D"NUTRICIONISTA" id=3D"group_503039759_3" r=ole=3D"checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
NUTRICIONISTA</span>
</label>
</li>
 <li class=3D"ss-choice-item" style=3D"margin:0;line-height:1.3=em;padding-bottom:.5em;">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"pos=ition:relative;display:inline-block;">
<input type=3D"checkbox" name=3D"entry=.503039759" disabled=3D"" value=3D"KINESIOLOGO" id=3D"group_503039759_4" rol=e=3D"checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
KINESIOLOGO</span>
</label>
</li>
 <li class=3D"ss-choice-item" style=3D"margin:0;line-height:1.3=em;padding-bottom:.5em;">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"pos=ition:relative;display:inline-block;">
<input type=3D"checkbox" name=3D"entry=.503039759" disabled=3D"" value=3D"PSICOLOGO" id=3D"group_503039759_5" role=3D="checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style=3D="margin:12px 0;max-width:100%;position:relative;">
<div class=3D"ss-form-entr=y" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-t=op:0;max-width:100%;">
<h2 class=3D"ss-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"ss-image" title=3D"" src=3D"=https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9=VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" 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%" role=3D"presentation">
<tbod=y>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.c=om/forms?usp=3Dmail_form_link" style=3D"color: #424242; font-size: 13px;">
Cr=ea tu propio formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
<=/blockquote>
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