<div>
<br>
</div>
<div>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr">
----------=C2=A0Mensaje reenviado=C2=A0---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Formularios de Google</strong>
 <span dir=3D"ltr">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Fecha: El s=C3=A1b, 30 de mar. de 2019 a las 22:00<br>
Asunto: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
Para:  &lt;<a href=3D"mailto:lilian.saavedra.vega@gmail.com">
lilian.saavedra.vega@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Formularios de Google" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por rellenar <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target=3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_6142179156974393586ss-form-container">
<div class=3D"m_6142179156974393586ss-form-heading">
<h1 class=3D"m_6142179156974393586ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_6142179156974393586ss-form-desc m_6142179156974393586ss-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_6142179156974393586ss-form">
<form method=3D"GET" id=3D"m_6142179156974393586ss-form" target=3D"_blank">
<br>
<div class=3D"m_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-item-required m_6142179156974393586ss-text" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586emailAddress">
<div class=3D"m_6142179156974393586ss-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_6142179156974393586emailAddress">
</label>
<span class=3D"m_6142179156974393586ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_6142179156974393586ss-q-text m_6142179156974393586ss-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:lilian.saavedra.vega@gmail.com" target=3D"_blank">
lilian.saavedra.vega@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_6142179156974393586ss-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_6142179156974393586ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_6142179156974393586ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_6142179156974393586ss-page-description m_6142179156974393586ss-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_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-item-required m_6142179156974393586ss-text" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_579114469">
<div class=3D"m_6142179156974393586ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_6142179156974393586itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6142179156974393586ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6142179156974393586ss-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%">
Lilian Saavedra </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-item-required m_6142179156974393586ss-text" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_1276273985">
<div class=3D"m_6142179156974393586ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_6142179156974393586itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6142179156974393586ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-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_6142179156974393586ss-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%">
18232709-3</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-item-required m_6142179156974393586ss-select" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_133691676">
<div class=3D"m_6142179156974393586ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_6142179156974393586itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6142179156974393586ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-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_6142179156974393586entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled selected>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_6142179156974393586ss-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_6142179156974393586ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_6142179156974393586ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_6142179156974393586ss-page-description m_6142179156974393586ss-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_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_6142179156974393586ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_6142179156974393586ss-section-description m_6142179156974393586ss-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_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-item-required m_6142179156974393586ss-text" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_823811303">
<div class=3D"m_6142179156974393586ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_6142179156974393586itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6142179156974393586ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-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_6142179156974393586ss-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%">
3053913-3</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-item-required m_6142179156974393586ss-text" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_1959365839">
<div class=3D"m_6142179156974393586ss-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_6142179156974393586itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6142179156974393586ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6142179156974393586ss-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%">
Juana del piano </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-item-required m_6142179156974393586ss-select" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_545002227">
<div class=3D"m_6142179156974393586ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_6142179156974393586itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6142179156974393586ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-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_6142179156974393586entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled>
COLMENA</option>
 <option value=3D"CONSALUD" disabled>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value==3D"ISAPRES DEL COBRE" disabled selected>
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_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-item-required m_6142179156974393586ss-text" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_1900161356">
<div class=3D"m_6142179156974393586ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_6142179156974393586itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6142179156974393586ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6142179156974393586ss-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%">
antofagasta </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-item-required m_6142179156974393586ss-text" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_1298871758">
<div class=3D"m_6142179156974393586ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_6142179156974393586itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6142179156974393586ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6142179156974393586ss-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%">
antofagasta </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_6142179156974393586ss-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_6142179156974393586ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_6142179156974393586ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_6142179156974393586ss-page-description m_6142179156974393586ss-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_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-item-required m_6142179156974393586ss-radio" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_2073233714">
<div class=3D"m_6142179156974393586ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_6142179156974393586itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6142179156974393586ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_6142179156974393586ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_6142179156974393586ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_6142179156974393586ss-choice-item-control m_6142179156974393586goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_6142179156974393586group_1222378237_1" class=3D"m_6142179156974393586ss-q-radio">
</span>
<span class=3D"m_6142179156974393586ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_6142179156974393586ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_6142179156974393586ss-choice-item-control m_6142179156974393586goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_6142179156974393586group_1222378237_2" class=3D"m_6142179156974393586ss-q-radio">
</span>
<span class=3D"m_6142179156974393586ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-item-required m_6142179156974393586ss-date" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_1705849412">
<div class=3D"m_6142179156974393586ss-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_6142179156974393586itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6142179156974393586ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6142179156974393586ss-q-date">
<div class=3D"m_6142179156974393586ss-datetime-box m_6142179156974393586goog-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_6142179156974393586ss-day-dropdown" id=3D"m_6142179156974393586entry.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>
 <option value=3D"5">
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>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
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14</option>
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15</option>
 <option value=3D"16">
16</option>
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17</option>
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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>
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25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
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28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30" selected>
30</option>
 <option value=3D"31">
31</option>
</select>
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<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
 <option value=3D"2">
febrero</option>
 <option value=3D"3" selected>
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>
 <option value=3D"12">
diciembre</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_6142179156974393586entry.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>
 <option value=3D"1902">
1902</option>
 <option value=3D"1903">
1903</option>
 <option value=3D"1904">
1904</option>
 <option value=3D"1905">
1905</option>
 <option value=3D"1906">
1906</option>
 <option value=3D"1907">
1907</option>
 <option value=3D"1908">
1908</option>
 <option value=3D"1909">
1909</option>
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1910</option>
 <option value=3D"1911">
1911</option>
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1912</option>
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1913</option>
 <option value=3D"1914">
1914</option>
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1915</option>
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1916</option>
 <option value=3D"1917">
1917</option>
 <option value=3D"1918">
1918</option>
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1919</option>
 <option value=3D"1920">
1920</option>
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1921</option>
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1922</option>
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1923</option>
 <option value==3D"1924">
1924</option>
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1925</option>
 <option value==3D"1926">
1926</option>
 <option value=3D"1927">
1927</option>
 <option value==3D"1928">
1928</option>
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1929</option>
 <option value==3D"1930">
1930</option>
 <option value=3D"1931">
1931</option>
 <option value==3D"1932">
1932</option>
 <option value=3D"1933">
1933</option>
 <option value==3D"1934">
1934</option>
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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>
 <option value==3D"1946">
1946</option>
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1947</option>
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1948</option>
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1949</option>
 <option value==3D"1950">
1950</option>
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1951</option>
 <option value==3D"1952">
1952</option>
 <option value=3D"1953">
1953</option>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
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1959</option>
 <option value==3D"1960">
1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
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1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
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1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
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1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
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1976</option>
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1977</option>
 <option value==3D"1978">
1978</option>
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1979</option>
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1980</option>
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1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
 <option value=3D"2011">
2011</option>
 <option value==3D"2012">
2012</option>
 <option value=3D"2013">
2013</option>
 <option value==3D"2014">
2014</option>
 <option value=3D"2015">
2015</option>
 <option value==3D"2016">
2016</option>
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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_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-item-required m_6142179156974393586ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_206244955">
<div class=3D"m_6142179156974393586ss-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_6142179156974393586itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6142179156974393586ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6142179156974393586ss-q-time">
<div class=3D"m_6142179156974393586ss-datetime-box m_6142179156974393586goog-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_6142179156974393586entry.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>
 <option value=3D"03">
03</option>
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04</option>
 <option value=3D"05">
05</option>
 <option value=3D"06">
06</option>
 <option value=3D"07">
07</option>
 <option value=3D"08">
08</option>
 <option value=3D"09">
09</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12" selected>
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>
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11</option>
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14</option>
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15</option>
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17</option>
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18</option>
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27</option>
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28</option>
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38</option>
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39</option>
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56</option>
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58</option>
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59</option>
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</div>
</div>
</div>
</div>
</div>
</div>
<br>
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<div class=3D"m_6142179156974393586ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_6142179156974393586itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6142179156974393586ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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</div>
</label>
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</option>
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0</option>
 <option value=3D"1" disabled selected>
1</option>
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2</option>
 <option value=3D"3" disabled>
3</option>
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4</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_1716090865">
<div class=3D"m_6142179156974393586ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-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_6142179156974393586entry_1421689035">
<tbody>
<tr>
<td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
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<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1421689035_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
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<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_6142179156974393586ss-scalerow m_6142179156974393586ss-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_6142179156974393586aria-todo">
</div>
</td>
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</div>
</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"1" id=3D"m_6142179156974393586group_1421689035_2" class=3D"m_6142179156974393586ss-q-radio">
</div>
</td>
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</div>
</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3" id=3D"m_6142179156974393586group_1421689035_4" class==3D"m_6142179156974393586ss-q-radio">
</div>
</td>
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<div class=3D"m_6142179156974393586ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_6142179156974393586group_1421689035_5" class=3D"m_6142179156974393586ss-q-radio">
</div>
</td>
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<div class=3D"m_6142179156974393586ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_6142179156974393586group_1421689035_6" class=3D"m_6142179156974393586ss-q-radio">
</div>
</td>
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<div class=3D"m_6142179156974393586ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_6142179156974393586group_1421689035_7" class=3D"m_6142179156974393586ss-q-radio">
</div>
</td>
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<div class=3D"m_6142179156974393586ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"7" id==3D"m_6142179156974393586group_1421689035_8" class=3D"m_6142179156974393586ss-q-radio">
</div>
</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_6142179156974393586group_1421689035_9" class=3D"m_6142179156974393586ss-q-radio">
</div>
</td>
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<div class=3D"m_6142179156974393586ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_6142179156974393586group_1421689035_10" class=3D"m_6142179156974393586ss-q-radio">
</div>
</td>
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<div class=3D"m_6142179156974393586ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"10" id=3D"m_6142179156974393586group_1421689035_11" class=3D"m_6142179156974393586ss-q-radio">
</div>
</td>
<td class=3D"m_6142179156974393586ss-scalerow m_6142179156974393586ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_2064050596">
<div class=3D"m_6142179156974393586ss-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_6142179156974393586ss-q-help m_6142179156974393586ss-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_6142179156974393586entry_1244707512">
<tbody>
<tr>
<td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_6142179156974393586ss-scalerow m_6142179156974393586ss-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_6142179156974393586aria-todo">
</div>
</td>
<td class=3D"m_6142179156974393586ss-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_6142179156974393586ss-scalerow-fieldcell">
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</div>
</td>
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<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
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<div class=3D"m_6142179156974393586ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=ADnimo</div>
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</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_6142179156974393586entry_853118630">
<tbody>
<tr>
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</td>
<td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
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0</label>
</td>
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1</label>
</td>
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<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_853118630_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
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<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_853118630_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
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4</label>
</td>
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<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_853118630_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_853118630_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
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<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_853118630_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_853118630_9" style==3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label class=3D"m_6142179156974393586ss-scalenumber" for=3D"m_6142179156974393586group_853118630_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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10</label>
</td>
<td class=3D"m_6142179156974393586ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_6142179156974393586ss-scalerow m_6142179156974393586ss-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_6142179156974393586aria-todo">
</div>
</td>
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</div>
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</div>
</td>
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</div>
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</div>
</td>
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</div>
</td>
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<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"5" id=3D"m_6142179156974393586group_853118630_6" class=3D"m_6142179156974393586ss-q-radio">
</div>
</td>
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</div>
</td>
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</div>
</td>
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</div>
</td>
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</div>
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<td class=3D"m_6142179156974393586ss-scalerow m_6142179156974393586ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
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</tbody>
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Anamnesis/Evoluci=C3=B3n<label for=3D"m_6142179156974393586itemView.getDomIdToLabel()">
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*</span>
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</div>
</label>
<div class=3D"m_6142179156974393586ss-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 es casado, tiene dos hijos, uno de ellos es ingeniero y el otro tiene un consumo problematico de drogas. Asimismo menciona que este proceso lo ha tenido que pasar dos veces antes, por lo tanto se percibe con las herramientas de pode afrontar un tercer cancer.=20En primera instancia menciona que no tiene dificultades con su cuerpo, si bien no puede agitarse debido a las quimioterapias , eso no impide que pueda realizar sus actividades de la vida diaria como trabajar o hacer actividades domesticas, sin embargo, menciona que mantiene dificultades para conciliar el sue=C3=B1o situacion que le provoca angustia ya que no puede descansar de buena manera. Sumado a eso menciona que durante la noche siente dolores muy fuertes que le provocan miedo.=20Se visualiza un estilo de afrontamiento adaptativo, ya que visualiza este proceso como una batalla que puede ganar, ya que se siente con energias y apoyado por su familia. Asimismo refiere que se siente tranquilo ya que este tiempo ha podido dejar todo listo con su empresa y otras acciones. </div>
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Examen F=C3=ADsico<label for=3D"m_6142179156974393586itemView.getDomIdToLabel()">
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Primera entrevista </div>
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<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_1690694733">
<div class=3D"m_6142179156974393586ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_6142179156974393586itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6142179156974393586ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6142179156974393586ss-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%">
no aplica </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-item-required m_6142179156974393586ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_1255665248">
<div class=3D"m_6142179156974393586ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_6142179156974393586itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6142179156974393586ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6142179156974393586ss-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%">
Terapia de apoyo </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_1648939075">
<div class=3D"m_6142179156974393586ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6142179156974393586ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-date" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_2063615873">
<div class=3D"m_6142179156974393586ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6142179156974393586ss-q-date">
<div class=3D"m_6142179156974393586ss-datetime-box m_6142179156974393586goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name=3D"entry.2063615873_day" disabled class=3D"m_6142179156974393586ss-day-dropdown" id=3D"m_6142179156974393586entry.2063615873_day">
<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
 <option value=3D"2">
2</option>
 <option value=3D"3">
3</option>
 <option value=3D"4">
4</option>
 <option value=3D"5">
5</option>
 <option value=3D"6">
6</option>
 <option value=3D"7">
7</option>
 <option value=3D"8">
8</option>
 <option value=3D"9">
9</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value==3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
 <option value=3D"23">
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>
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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>
 <option value=3D"2">
febrero</option>
 <option value=3D"3">
marzo</option>
 <option value=3D"4">
abril</option>
 <option value=3D"5">
mayo</option>
 <option value=3D"6">
junio</option>
 <option value==3D"7">
julio</option>
 <option value=3D"8">
agosto</option>
 <option value=3D"9">
septiembre</option>
 <option value=3D"10">
octubre</option>
 <option value==3D"11">
noviembre</option>
 <option value=3D"12">
diciembre</option>
</select>
=20<select name=3D"entry.2063615873_year" disabled id=3D"m_6142179156974393586entry.2063615873_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>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
1901</option>
 <option value=3D"1902">
1902</option>
 <option value=3D"1903">
1903</option>
 <option value=3D"1904">
1904</option>
 <option value=3D"1905">
1905</option>
 <option value=3D"1906">
1906</option>
 <option value=3D"1907">
1907</option>
 <option value=3D"1908">
1908</option>
 <option value=3D"1909">
1909</option>
 <option value=3D"1910">
1910</option>
 <option value=3D"1911">
1911</option>
 <option value=3D"1912">
1912</option>
 <option value=3D"1913">
1913</option>
 <option value=3D"1914">
1914</option>
 <option value=3D"1915">
1915</option>
 <option value=3D"1916">
1916</option>
 <option value=3D"1917">
1917</option>
 <option value=3D"1918">
1918</option>
 <option value=3D"1919">
1919</option>
 <option value=3D"1920">
1920</option>
 <option value=3D"1921">
1921</option>
 <option value=3D"1922">
1922</option>
 <option value=3D"1923">
1923</option>
 <option value==3D"1924">
1924</option>
 <option value=3D"1925">
1925</option>
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1926</option>
 <option value=3D"1927">
1927</option>
 <option value==3D"1928">
1928</option>
 <option value=3D"1929">
1929</option>
 <option value==3D"1930">
1930</option>
 <option value=3D"1931">
1931</option>
 <option value==3D"1932">
1932</option>
 <option value=3D"1933">
1933</option>
 <option value==3D"1934">
1934</option>
 <option value=3D"1935">
1935</option>
 <option value==3D"1936">
1936</option>
 <option value=3D"1937">
1937</option>
 <option value==3D"1938">
1938</option>
 <option value=3D"1939">
1939</option>
 <option value==3D"1940">
1940</option>
 <option value=3D"1941">
1941</option>
 <option value==3D"1942">
1942</option>
 <option value=3D"1943">
1943</option>
 <option value==3D"1944">
1944</option>
 <option value=3D"1945">
1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
1948</option>
 <option value=3D"1949">
1949</option>
 <option value==3D"1950">
1950</option>
 <option value=3D"1951">
1951</option>
 <option value==3D"1952">
1952</option>
 <option value=3D"1953">
1953</option>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
 <option value=3D"1959">
1959</option>
 <option value==3D"1960">
1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
1976</option>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
 <option value==3D"1980">
1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
 <option value=3D"2011">
2011</option>
 <option value==3D"2012">
2012</option>
 <option value=3D"2013">
2013</option>
 <option value==3D"2014">
2014</option>
 <option value=3D"2015">
2015</option>
 <option value==3D"2016">
2016</option>
 <option value=3D"2017">
2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-text" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_74766472">
<div class=3D"m_6142179156974393586ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_6142179156974393586ss-q-help m_6142179156974393586ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6142179156974393586ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586ss-form-question m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6142179156974393586ss-q-item-label" for=3D"m_6142179156974393586entry_1219705969">
<div class=3D"m_6142179156974393586ss-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_6142179156974393586ss-q-help m_6142179156974393586ss-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_6142179156974393586ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_6142179156974393586ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_6142179156974393586ss-choice-item-control m_6142179156974393586goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"ENFERMERA" id=3D"m_6142179156974393586group_503039759_1" class=3D"m_6142179156974393586ss-q-checkbox">
</span>
<span class=3D"m_6142179156974393586ss-choice-label">
ENFERMERA</span>
</label>
</li>
 <li class=3D"m_6142179156974393586ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_6142179156974393586ss-choice-item-control m_6142179156974393586goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_6142179156974393586group_503039759_2" class=3D"m_6142179156974393586ss-q-checkbox">
</span>
<span class=3D"m_6142179156974393586ss-choice-label">
TENS</span>
</label>
</li>
 <li class=3D"m_6142179156974393586ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_6142179156974393586ss-choice-item-control m_6142179156974393586goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id==3D"m_6142179156974393586group_503039759_3" class=3D"m_6142179156974393586ss-q-checkbox">
</span>
<span class=3D"m_6142179156974393586ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
 <li class=3D"m_6142179156974393586ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_6142179156974393586ss-choice-item-control m_6142179156974393586goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"KINESIOLOGO" id=3D"m_6142179156974393586group_503039759_4" class=3D"m_6142179156974393586ss-q-checkbox">
</span>
<span class=3D"m_6142179156974393586ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
 <li class=3D"m_6142179156974393586ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_6142179156974393586ss-choice-item-control m_6142179156974393586goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"PSICOLOGO" id=3D"m_6142179156974393586group_503039759_5" class=3D"m_6142179156974393586ss-q-checkbox">
</span>
<span class=3D"m_6142179156974393586ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_6142179156974393586errorbox-good">
<div dir=3D"auto" class=3D"m_6142179156974393586ss-item m_6142179156974393586ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_6142179156974393586ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_6142179156974393586ss-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_6142179156974393586ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
</form>
</div>
</div>
</td>
</tr>
<tr height=3D"24px">
</tr>
</tbody>
</table>
</div>
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"max-width:672px;min-width:154px" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242;font-size:13px" target=3D"_blank">
Crea tu propio formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
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