<div>
<br>
</div>
<div>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class==3D"gmail_attr">
----------=C2=A0Mensaje reenviado=C2=A0---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Marisol Rodriguez</strong>
 <span dir=3D"ltr">
&lt;<a href=3D"mailto:mari.rdgz@gmail.com">
mari.rdgz@gmail.com</a>
&gt;</span>
<br>
Fecha: El vie, 5 de abr. de 2019 a las 09:40<br>
Asunto: Marlene 2 atenci=C3=B3n domiciliaria nutricionista <br>
Para:  &lt;<a href=3D"mailto:esperanza.oyarzun@gmail.com">
esperanza.oyarzun@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div dir=3D"auto">
<br>
<br>
<div id=3D"m_2143405511290892776AppleMailSignature" dir=3D"ltr">
Enviado desde mi iPhone</div>
<div dir=3D"ltr">
<br>
Inicio del mensaje reenviado:<br>
<br>
</div>
<blockquote type=3D"cite">
<div dir=3D"ltr">
<b>
De:</b>
 Google Forms &lt;<a href=3D"mailto:forms-receipts-noreply@google.com" target=3D"_blank">
forms-receipts-noreply@google.com</a>
&gt;<br>
<b>
Fecha:</b>
 29 de marzo de 2019, 8:07:24 p. m. GMT-3<br>
<b>
Para:</b>
 <a href=3D"mailto:mari.rdgz@gmail.com" target=3D"_blank">
mari.rdgz@gmail.com</a>
<br>
<b>
Asunto:</b>
 <b>
Registro de Atenci=C3=B3n Domiciliaria Oncovida</b>
<br>
<br>
</div>
</blockquote>
<blockquote type=3D"cite">
<div dir==3D"ltr">
<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"Google Forms" 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">
Thanks for filling out <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">
Here&#39;s what we got from you:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_2143405511290892776ss-form-container">
<div class=3D"m_2143405511290892776ss-form-heading">
<h1 class=3D"m_2143405511290892776ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_2143405511290892776ss-form-desc m_2143405511290892776ss-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_2143405511290892776ss-form">
<form method=3D"GET" id=3D"m_2143405511290892776ss-form" target=3D"_blank">
<br>
<div class=3D"m_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-item-required m_2143405511290892776ss-text" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776emailAddress">
<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Email address<label for=3D"m_2143405511290892776emailAddress">
</label>
<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_2143405511290892776ss-q-text m_2143405511290892776ss-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:mari.rdgz@gmail.com" target=3D"_blank">
mari.rdgz@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2143405511290892776ss-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_2143405511290892776ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2143405511290892776ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_2143405511290892776ss-page-description m_2143405511290892776ss-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_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-item-required m_2143405511290892776ss-text" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_579114469">
<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_2143405511290892776itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2143405511290892776ss-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%">
Marisol Rodriguez</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-item-required m_2143405511290892776ss-text" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_1276273985">
<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_2143405511290892776itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-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_2143405511290892776ss-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%">
26721628-2</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-item-required m_2143405511290892776ss-select" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_133691676">
<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_2143405511290892776itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-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_2143405511290892776entry_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>
PSICOLOGO</option>
 <option value=3D"NUTRICIONISTA" disabled selected>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2143405511290892776ss-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_2143405511290892776ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2143405511290892776ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_2143405511290892776ss-page-description m_2143405511290892776ss-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_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2143405511290892776ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_2143405511290892776ss-section-description m_2143405511290892776ss-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_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-item-required m_2143405511290892776ss-text" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_823811303">
<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_2143405511290892776itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-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_2143405511290892776ss-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%">
11502419-1</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-item-required m_2143405511290892776ss-text" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_1959365839">
<div class=3D"m_2143405511290892776ss-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_2143405511290892776itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2143405511290892776ss-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%">
Marlena Vargas</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-item-required m_2143405511290892776ss-select" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_545002227">
<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_2143405511290892776itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-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_2143405511290892776entry_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 selected>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled>
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled>
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-item-required m_2143405511290892776ss-text" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_1900161356">
<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_2143405511290892776itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2143405511290892776ss-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%">
Puerto Montt</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-item-required m_2143405511290892776ss-text" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_1298871758">
<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_2143405511290892776itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2143405511290892776ss-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%">
Puerto Montt</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2143405511290892776ss-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_2143405511290892776ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2143405511290892776ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_2143405511290892776ss-page-description m_2143405511290892776ss-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_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-item-required m_2143405511290892776ss-radio" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_2073233714">
<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_2143405511290892776itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_2143405511290892776ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_2143405511290892776ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2143405511290892776ss-choice-item-control m_2143405511290892776goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_2143405511290892776group_1222378237_1" class=3D"m_2143405511290892776ss-q-radio">
</span>
<span class=3D"m_2143405511290892776ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_2143405511290892776ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2143405511290892776ss-choice-item-control m_2143405511290892776goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_2143405511290892776group_1222378237_2" class=3D"m_2143405511290892776ss-q-radio">
</span>
<span class=3D"m_2143405511290892776ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-item-required m_2143405511290892776ss-date" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_1705849412">
<div class=3D"m_2143405511290892776ss-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_2143405511290892776itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2143405511290892776ss-q-date">
<div class=3D"m_2143405511290892776ss-datetime-box m_2143405511290892776goog-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_month" disabled class=3D"m_2143405511290892776ss-month-dropdown" id=3D"m_2143405511290892776entry.1705849412_month">
<option value=3D"">
Month</option>
<option value=3D"1">
January</option>
 <option value=3D"2">
February</option>
 <option value=3D"3" selected>
March</option>
 <option value=3D"4">
April</option>
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May</option>
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June</option>
 <option value=3D"7">
July</option>
 <option value=3D"8">
August</option>
 <option value=3D"9">
September</option>
 <option value=3D"10">
October</option>
 <option value=3D"11">
November</option>
 <option value=3D"12">
December</option>
</select>
   <select name=3D"entry.1705849412_day" disabled class=3D"m_2143405511290892776ss-day-dropdown" id=3D"m_2143405511290892776entry.1705849412_day">
<option value=3D"">
Day</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" selected>
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_2143405511290892776entry.1705849412_year">
<option value=3D"">
Year</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
 <option value=3D"1898">
1898</option>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
1901</option>
 <option value=3D"1902">
1902</option>
 <option value=3D"1903">
1903</option>
 <option value=3D"1904">
1904</option>
 <option value=3D"1905">
1905</option>
 <option value=3D"1906">
1906</option>
 <option value=3D"1907">
1907</option>
 <option value=3D"1908">
1908</option>
 <option value=3D"1909">
1909</option>
 <option value=3D"1910">
1910</option>
 <option value=3D"1911">
1911</option>
 <option value=3D"1912">
1912</option>
 <option value=3D"1913">
1913</option>
 <option value=3D"1914">
1914</option>
 <option value=3D"1915">
1915</option>
 <option value=3D"1916">
1916</option>
 <option value=3D"1917">
1917</option>
 <option value=3D"1918">
1918</option>
 <option value=3D"1919">
1919</option>
 <option value=3D"1920">
1920</option>
 <option value=3D"1921">
1921</option>
 <option value=3D"1922">
1922</option>
 <option value=3D"1923">
1923</option>
 <option value==3D"1924">
1924</option>
 <option value=3D"1925">
1925</option>
 <option value==3D"1926">
1926</option>
 <option value=3D"1927">
1927</option>
 <option value==3D"1928">
1928</option>
 <option value=3D"1929">
1929</option>
 <option value==3D"1930">
1930</option>
 <option value=3D"1931">
1931</option>
 <option value==3D"1932">
1932</option>
 <option value=3D"1933">
1933</option>
 <option value==3D"1934">
1934</option>
 <option value=3D"1935">
1935</option>
 <option value==3D"1936">
1936</option>
 <option value=3D"1937">
1937</option>
 <option value==3D"1938">
1938</option>
 <option value=3D"1939">
1939</option>
 <option value==3D"1940">
1940</option>
 <option value=3D"1941">
1941</option>
 <option value==3D"1942">
1942</option>
 <option value=3D"1943">
1943</option>
 <option value==3D"1944">
1944</option>
 <option value=3D"1945">
1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
1948</option>
 <option value=3D"1949">
1949</option>
 <option value==3D"1950">
1950</option>
 <option value=3D"1951">
1951</option>
 <option value==3D"1952">
1952</option>
 <option value=3D"1953">
1953</option>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
 <option value=3D"1959">
1959</option>
 <option value==3D"1960">
1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
1976</option>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
 <option value==3D"1980">
1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
 <option value=3D"2011">
2011</option>
 <option value==3D"2012">
2012</option>
 <option value=3D"2013">
2013</option>
 <option value==3D"2014">
2014</option>
 <option value=3D"2015">
2015</option>
 <option value==3D"2016">
2016</option>
 <option value=3D"2017">
2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-item-required m_2143405511290892776ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_206244955">
<div class=3D"m_2143405511290892776ss-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_2143405511290892776itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2143405511290892776ss-q-time">
<div class=3D"m_2143405511290892776ss-datetime-box m_2143405511290892776goog-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_2143405511290892776entry.206244955_hour">
<option value=3D"">
Hr</option>
<option value=3D"01">
01</option>
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</div>
</div>
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<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_2143405511290892776itemView.getDomIdToLabel()">
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<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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1</option>
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2</option>
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3</option>
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4</option>
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</div>
</div>
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 <div class=3D"m_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
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<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_1716090865">
<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
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</td>
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<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
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<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
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<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1421689035_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
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<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
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<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
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5</label>
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6</label>
</td>
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<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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10</label>
</td>
<td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
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<div class=3D"m_2143405511290892776aria-todo">
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</div>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_2143405511290892776group_1421689035_10" class=3D"m_2143405511290892776ss-q-radio">
</div>
</td>
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<div class==3D"m_2143405511290892776ss-scalerow-fieldcell">
<input type=3D"radio" name==3D"entry.1421689035" disabled value=3D"10" id=3D"m_2143405511290892776group_1421689035_11" class=3D"m_2143405511290892776ss-q-radio">
</div>
</td>
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</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_2064050596">
<div class=3D"m_2143405511290892776ss-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_2143405511290892776ss-q-help m_2143405511290892776ss-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_2143405511290892776entry_1244707512">
<tbody>
<tr>
<td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
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<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
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<div class=3D"m_2143405511290892776aria-todo">
</div>
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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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</div>
</td>
<td class=3D"m_2143405511290892776ss-scalerow m_2143405511290892776ss-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>
</table>
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<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_2143405511290892776ss-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_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=ADnimo</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-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_2143405511290892776entry_853118630">
<tbody>
<tr>
<td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_853118630_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
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1</label>
</td>
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<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_853118630_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
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<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_853118630_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
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<label class==3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_853118630_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
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<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_853118630_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_853118630_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
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<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_853118630_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_853118630_9" style==3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_853118630_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2143405511290892776ss-scalenumber" for=3D"m_2143405511290892776group_853118630_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_2143405511290892776ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_2143405511290892776ss-scalerow m_2143405511290892776ss-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_2143405511290892776aria-todo">
</div>
</td>
<td class=3D"m_2143405511290892776ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
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</div>
</td>
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<input type=3D"radio" name=3D"entry.853118630" disabled checked value=3D"1" id=3D"m_2143405511290892776group_853118630_2" class=3D"m_2143405511290892776ss-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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<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"5" id=3D"m_2143405511290892776group_853118630_6" class=3D"m_2143405511290892776ss-q-radio">
</div>
</td>
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<div class=3D"m_2143405511290892776ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"6" id=3D"m_2143405511290892776group_853118630_7" class=3D"m_2143405511290892776ss-q-radio">
</div>
</td>
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<div class=3D"m_2143405511290892776ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"7" id=3D"m_2143405511290892776group_853118630_8" class=3D"m_2143405511290892776ss-q-radio">
</div>
</td>
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<div class=3D"m_2143405511290892776ss-scalerow-fieldcell">
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</div>
</td>
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<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"9" id=3D"m_2143405511290892776group_853118630_10" class=3D"m_2143405511290892776ss-q-radio">
</div>
</td>
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<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"10" id=3D"m_2143405511290892776group_853118630_11" class==3D"m_2143405511290892776ss-q-radio">
</div>
</td>
<td class=3D"m_2143405511290892776ss-scalerow m_2143405511290892776ss-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>
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</tbody>
</table>
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<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_2140974612">
<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Anamnesis/Evoluci=C3=B3n<label for=3D"m_2143405511290892776itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2143405511290892776ss-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 femenina de 50 a=C3=B1os de edad con diagnostico medico de ca de mamas, la cual se realizo atenci=C3=B3n control, encontrando un resultado satisfactorio planteado en la ultima consulta el cual era reestablecer el orden de las comidas. Anamnesis recordatorio 24 horas:=20Desayuno--&gt; Yogurt griego 1/2 taza con fruta picada (pera y platano)Merienda--&gt; Caf=C3=A9 mas pan blanco con mermelada=20Comida pre almuerzo--&gt; Ensalada de frutas; mel=C3=B3n, pera, platano y naranja.Almuerzo--&gt; Arroz blanco con salchicha y dos huevos fritos.Once--&gt; Te mas s=C3=A1ndwich integral con queso chanco, 3 rebanadas de salami, mayonesa y palta.No cen=C3=B3.Adecuaci=C3=B3n diet=C3=A9tica normal en macronutrienes y energ=C3=ADa.</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-item-required m_2143405511290892776ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_824006088">
<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen F=C3=ADsico<label for=3D"m_2143405511290892776itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2143405511290892776ss-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%">
Antropometr=C3=ADa: Peso 71.6kg, talla 1,60mts, IMC: 27.9. Al examen f=C3=ADsico no evidenciaba deficiencias de macro o micronutrientes, solo refiere acidez intermitente luego de consumir medicamentos, el cual refiere no se presenta cuando ingiere ranitidina. Su ritmo evacuatorio es normal, pero refiere heces tipo dos en escala de bristol.</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-item-required m_2143405511290892776ss-text" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_1690694733">
<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_2143405511290892776itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2143405511290892776ss-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%">
Sobrepeso grado 2</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-item-required m_2143405511290892776ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_1255665248">
<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_2143405511290892776itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2143405511290892776ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2143405511290892776ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Se reviso la alimentaci=C3=B3n y se incluyeron alimentos ricos en antioxidantes, tambi=C3=A9n se le brindo educaci=C3=B3n nutricional para preferir el consumo de alimentos que aceleran el vaciamiento g=C3=A1strico y no irritan la mucosa g=C3=A1strica, para prevenir la acidez, asi mismo se recomienda dieta rica en fibra soluble y probi==C3=B3ticos para ablandar la consistencia de las heces.</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_1648939075">
<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2143405511290892776ss-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_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-date" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_2063615873">
<div class=3D"m_2143405511290892776ss-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_2143405511290892776ss-q-help m_2143405511290892776ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2143405511290892776ss-q-date">
<div class=3D"m_2143405511290892776ss-datetime-box m_2143405511290892776goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
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<option value=3D"">
Month</option>
<option value=3D"1">
January</option>
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February</option>
 <option value=3D"3">
March</option>
 <option value=3D"4" selected>
April</option>
 <option value=3D"5">
May</option>
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June</option>
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July</option>
 <option value=3D"8">
August</option>
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September</option>
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October</option>
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November</option>
 <option value=3D"12">
December</option>
</select>
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<option value=3D"">
Day</option>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
 <option value=3D"29">
29</option>
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30</option>
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31</option>
</select>
=20<select name=3D"entry.2063615873_year" disabled id=3D"m_2143405511290892776entry.2063615873_year">
<option value=3D"">
Year</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>
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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>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
 <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>
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1924</option>
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1925</option>
 <option value==3D"1926">
1926</option>
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1927</option>
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1928</option>
 <option value=3D"1929">
1929</option>
 <option value==3D"1930">
1930</option>
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1931</option>
 <option value==3D"1932">
1932</option>
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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>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
 <option value==3D"1960">
1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
 <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>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
 <option value==3D"1998">
1998</option>
 <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>
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2004</option>
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2005</option>
 <option value==3D"2006">
2006</option>
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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_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-text" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_74766472">
<div class=3D"m_2143405511290892776ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_2143405511290892776ss-q-help m_2143405511290892776ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2143405511290892776ss-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_2143405511290892776ss-form-question m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2143405511290892776ss-q-item-label" for=3D"m_2143405511290892776entry_1219705969">
<div class=3D"m_2143405511290892776ss-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_2143405511290892776ss-q-help m_2143405511290892776ss-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_2143405511290892776ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_2143405511290892776ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2143405511290892776ss-choice-item-control m_2143405511290892776goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"ENFERMERA" id=3D"m_2143405511290892776group_503039759_1" class=3D"m_2143405511290892776ss-q-checkbox">
</span>
<span class=3D"m_2143405511290892776ss-choice-label">
ENFERMERA</span>
</label>
</li>
 <li class=3D"m_2143405511290892776ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2143405511290892776ss-choice-item-control m_2143405511290892776goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_2143405511290892776group_503039759_2" class=3D"m_2143405511290892776ss-q-checkbox">
</span>
<span class=3D"m_2143405511290892776ss-choice-label">
TENS</span>
</label>
</li>
 <li class=3D"m_2143405511290892776ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2143405511290892776ss-choice-item-control m_2143405511290892776goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id==3D"m_2143405511290892776group_503039759_3" class=3D"m_2143405511290892776ss-q-checkbox">
</span>
<span class=3D"m_2143405511290892776ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
 <li class=3D"m_2143405511290892776ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2143405511290892776ss-choice-item-control m_2143405511290892776goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"KINESIOLOGO" id=3D"m_2143405511290892776group_503039759_4" class=3D"m_2143405511290892776ss-q-checkbox">
</span>
<span class=3D"m_2143405511290892776ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
 <li class=3D"m_2143405511290892776ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2143405511290892776ss-choice-item-control m_2143405511290892776goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"PSICOLOGO" id=3D"m_2143405511290892776group_503039759_5" class=3D"m_2143405511290892776ss-q-checkbox">
</span>
<span class=3D"m_2143405511290892776ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_2143405511290892776errorbox-good">
<div dir=3D"auto" class=3D"m_2143405511290892776ss-item m_2143405511290892776ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_2143405511290892776ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2143405511290892776ss-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_2143405511290892776ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</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">
Create your own Google Form</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</blockquote>
</div>
</div>
</div>
-- <br>
<div dir=3D"ltr" class=3D"gmail_signature" data-smartmail=3D"gmail_signature">
<div dir=3D"ltr">
M=C2=AA Esperanza Oyarz=C3=BAn S.<br>
Cel: 78879565<br>
</div>
</div>
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