<HTML>
<BODY>
<p style="margin-top: 0px;" dir="ltr">
</p>
 <div id="mail-app-auto-default-signature">
 <p dir="ltr">
--<br>
 Sandra Maulen Angel<br>
 Enfermera <br>
 Coordinadora<br>
 Telemed-chile</p>
</div>
-------- Mensaje reenviado --------De: Rafael Richard <a href="mailto:rafaelrichardc@gmail.com">
rafaelrichardc@gmail.com</a>
Para: <a href="mailto:coordinadora@telemed-chile.cl">
coordinadora@telemed-chile.cl</a>
Fecha: domingo, 21 abril 2019, 05:08p. m. -04:00Asunto: Fwd: Registro de Atención Domiciliaria Oncovida<br>
<br>
<blockquote id="mail-app-auto-quote" cite="15558809010000002521" style="border-left:1px solid #FC2C38; margin:0px 0px 0px 10px; padding:0px 0px 0px 10px;">
	    											<div class="js-helper js-readmsg-msg">
	<style type="text/css">
</style>
 	<div >
		<base target="_self" href="https://e-aj.my.com/" />
					<div id="style_15558809010000002521_BODY">
<div class="class_1555893216">
<div dir="ltr">
Estimada,<div>
<br>
</div>
<div>
Reenvío Formulario correspondiente a atención realizada el 16/04/2019.</div>
<div>
<br>
</div>
<div>
Saludos cordiales,<br>
<br>
<div class="gmail_quote_mailru_css_attribute_postfix">
<div dir="ltr" class="gmail_attr_mailru_css_attribute_postfix">
---------- Forwarded message ---------<br>
De: <strong class="gmail_sendername_mailru_css_attribute_postfix" dir="auto">
Formularios de Google</strong>
 <span dir="ltr">
<<a href="mailto:forms-receipts-noreply@google.com" target="_blank" rel=" noopener noreferrer" >
forms-receipts-noreply@google.com</a>
>
</span>
<br>
Date: mar., 16 abr. 2019 a las 15:38<br>
Subject: Registro de Atención Domiciliaria Oncovida<br>
To:  <<a href="mailto:rafaelrichardc@gmail.com" target="_blank" rel=" noopener noreferrer" >
rafaelrichardc@gmail.com</a>
>
<br>
</div>
<br>
<br>
<div style="font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border="0" cellpadding="0" cellspacing="0" style="background-color:rgb(38,4,154)" width="100%">
<tbody>
<tr height="64px">
<td style="padding-left:24px">
<img alt="Formularios de Google" height="26px" style="display:inline-block;margin:0;vertical-align:middle" width="143px" src="https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style="padding:24px;background-color:rgb(229,218,254)">
<div align="center" style="background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align="center" cellpadding="0" cellspacing="0" style="background-color:#fff" width="100%">
<tbody>
<tr height="24px">
<td>
</td>
</tr>
<tr>
<td>
<div style="font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por rellenar <a href="https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=mail_form_link" target="_blank" rel=" noopener noreferrer" >
Registro de Atención Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height="12px">
</tr>
<tr>
<td>
<div style="font-size:13px;line-height:18px;color:#424242">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-container_mailru_css_attribute_postfix">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-heading_mailru_css_attribute_postfix">
<h1 class="m_-1616745373956918955m_-2655095683506931684ss-form-title_mailru_css_attribute_postfix" dir="ltr" style="margin:.67em 0">
Registro de Atención Domiciliaria Oncovida</h1>
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-desc_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-no-ignore-whitespace_mailru_css_attribute_postfix" style="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 continuación indique su correo electrónico.</div>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-form_mailru_css_attribute_postfix">
<form id="m_-1616745373956918955m_-2655095683506931684ss-form_mailru_css_attribute_postfix" target="_blank" action="#" method="POST" onsubmit="return false"  rel=" noopener noreferrer" >
<br>
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Dirección de correo electrónico<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-text_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-printable-text-line_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
<a href="mailto:rafaelrichardc@gmail.com" target="_blank" rel=" noopener noreferrer" >
rafaelrichardc@gmail.com</a>
</div>
</div>
</div>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-embeddable-object-container_mailru_css_attribute_postfix" style="margin:12px 0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style="text-align:right">
<img class="m_-1616745373956918955m_-2655095683506931684ss-image_mailru_css_attribute_postfix" title="" src="https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style="width:78px;outline:none" alt="Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-page-break_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="m_-1616745373956918955m_-2655095683506931684ss-page-title_mailru_css_attribute_postfix" style="padding:0.4em;background-color:#eee">
Identificación del Prestador</h2>
<div class="m_-1616745373956918955m_-2655095683506931684ss-page-description_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-no-ignore-whitespace_mailru_css_attribute_postfix" dir="auto" style="white-space:pre-wrap;word-wrap:break-word">
Aquí debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Rafael Richard </div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
17082479-2</div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-select_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
Si asisten más de 1 prestador simultáneamente, cada uno debe hacer un registro independiente</div>
<select name="entry.133691676" id="m_-1616745373956918955m_-2655095683506931684entry_133691676_mailru_css_attribute_postfix">
<option value="">
</option>
<option value="MEDICO" >
MEDICO</option>
 <option value="ENFERMERA/O" >
ENFERMERA/O</option>
 <option value="TENS" >
TENS</option>
 <option value="KINESIOLOGA/O" >
KINESIOLOGA/O</option>
 <option value="PSICOLOGO" >
PSICOLOGO</option>
 <option value="NUTRICIONISTA" >
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-embeddable-object-container_mailru_css_attribute_postfix" style="margin:12px 0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style="text-align:right">
<img class="m_-1616745373956918955m_-2655095683506931684ss-image_mailru_css_attribute_postfix" title="" src="https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style="width:78px;outline:none" alt="Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-page-break_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="m_-1616745373956918955m_-2655095683506931684ss-page-title_mailru_css_attribute_postfix" style="padding:0.4em;background-color:#eee">
Identificación del Paciente</h2>
<div class="m_-1616745373956918955m_-2655095683506931684ss-page-description_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-no-ignore-whitespace_mailru_css_attribute_postfix" dir="auto" style="white-space:pre-wrap;word-wrap:break-word">
En esta sección debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-section-header_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="m_-1616745373956918955m_-2655095683506931684ss-section-title_mailru_css_attribute_postfix" style="background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class="m_-1616745373956918955m_-2655095683506931684ss-section-description_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-no-ignore-whitespace_mailru_css_attribute_postfix" style="margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word">
</div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
7986475-7</div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
John McVey </div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-select_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsión<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<select name="entry.545002227" id="m_-1616745373956918955m_-2655095683506931684entry_545002227_mailru_css_attribute_postfix">
<option value="">
</option>
<option value="BANMEDICA" >
BANMEDICA</option>
 <option value="CAPREDENA" >
CAPREDENA</option>
 <option value="COLMENA" >
COLMENA</option>
 <option value="CONSALUD" >
CONSALUD</option>
 <option value="CRUZ BLANCA" >
CRUZ BLANCA</option>
 <option value="DIPRECA" >
DIPRECA</option>
 <option value="FONASA" >
FONASA</option>
 <option value="FUNDACION" >
FUNDACION</option>
 <option value="ISAPRES DEL COBRE" >
ISAPRES DEL COBRE</option>
 <option value="NUEVA MASVIDA" >
NUEVA MASVIDA</option>
 <option value="VIDATRES" >
VIDATRES</option>
 <option value="PARTICULAR" >
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Curacaví </div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Curacaví </div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-embeddable-object-container_mailru_css_attribute_postfix" style="margin:12px 0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style="text-align:right">
<img class="m_-1616745373956918955m_-2655095683506931684ss-image_mailru_css_attribute_postfix" title="" src="https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style="width:78px;outline:none" alt="Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-page-break_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="m_-1616745373956918955m_-2655095683506931684ss-page-title_mailru_css_attribute_postfix" style="padding:0.4em;background-color:#eee">
Registro de la Atención Domiciliaria</h2>
<div class="m_-1616745373956918955m_-2655095683506931684ss-page-description_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-no-ignore-whitespace_mailru_css_attribute_postfix" dir="auto" style="white-space:pre-wrap;word-wrap:break-word">
En esta sección debe ingresar los datos de la atención domiciliaria</div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-radio_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atención<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<ul class="m_-1616745373956918955m_-2655095683506931684ss-choices_mailru_css_attribute_postfix" style="list-style:none;padding:0;margin:.5em 0 0">
<li class="m_-1616745373956918955m_-2655095683506931684ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<span class="m_-1616745373956918955m_-2655095683506931684ss-choice-item-control_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block">
<input type="radio" name="entry.1222378237" value="Domicilio" id="m_-1616745373956918955m_-2655095683506931684group_1222378237_1_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</span>
<span class="m_-1616745373956918955m_-2655095683506931684ss-choice-label_mailru_css_attribute_postfix">
Domicilio</span>
</li>
 <li class="m_-1616745373956918955m_-2655095683506931684ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<span class="m_-1616745373956918955m_-2655095683506931684ss-choice-item-control_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block">
<input type="radio" name="entry.1222378237" value="Ambulatorio" id="m_-1616745373956918955m_-2655095683506931684group_1222378237_2_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</span>
<span class="m_-1616745373956918955m_-2655095683506931684ss-choice-label_mailru_css_attribute_postfix">
Ambulatorio</span>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-date_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha de la Atención<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-date_mailru_css_attribute_postfix">
<div class="m_-1616745373956918955m_-2655095683506931684ss-datetime-box_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684goog-inline-block_mailru_css_attribute_postfix" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name="entry.1705849412_day" class="m_-1616745373956918955m_-2655095683506931684ss-day-dropdown_mailru_css_attribute_postfix" >
<option value="">
Día</option>
<option value="1">
1</option>
 <option value="2">
2</option>
 <option value="3">
3</option>
 <option value="4">
4</option>
 <option value="5">
5</option>
 <option value="6">
6</option>
 <option value="7">
7</option>
 <option value="8">
8</option>
 <option value="9">
9</option>
 <option value="10">
10</option>
 <option value="11">
11</option>
 <option value="12">
12</option>
 <option value="13">
13</option>
 <option value="14">
14</option>
 <option value="15">
15</option>
 <option value="16" >
16</option>
 <option value="17">
17</option>
 <option value="18">
18</option>
 <option value="19">
19</option>
 <option value="20">
20</option>
 <option value="21">
21</option>
 <option value="22">
22</option>
 <option value="23">
23</option>
 <option value="24">
24</option>
 <option value="25">
25</option>
 <option value="26">
26</option>
 <option value="27">
27</option>
 <option value="28">
28</option>
 <option value="29">
29</option>
 <option value="30">
30</option>
 <option value="31">
31</option>
</select>
   <select name="entry.1705849412_month" class="m_-1616745373956918955m_-2655095683506931684ss-month-dropdown_mailru_css_attribute_postfix" >
<option value="">
Mes</option>
<option value="1">
enero</option>
 <option value="2">
febrero</option>
 <option value="3">
marzo</option>
 <option value="4" >
abril</option>
 <option value="5">
mayo</option>
 <option value="6">
junio</option>
 <option value="7">
julio</option>
 <option value="8">
agosto</option>
 <option value="9">
septiembre</option>
 <option value="10">
octubre</option>
 <option value="11">
noviembre</option>
 <option value="12">
diciembre</option>
</select>
 <select name="entry.1705849412_year" >
<option value="">
Año</option>
<option value="1896">
1896</option>
 <option value="1897">
1897</option>
 <option value="1898">
1898</option>
 <option value="1899">
1899</option>
 <option value="1900">
1900</option>
 <option value="1901">
1901</option>
 <option value="1902">
1902</option>
 <option value="1903">
1903</option>
 <option value="1904">
1904</option>
 <option value="1905">
1905</option>
 <option value="1906">
1906</option>
 <option value="1907">
1907</option>
 <option value="1908">
1908</option>
 <option value="1909">
1909</option>
 <option value="1910">
1910</option>
 <option value="1911">
1911</option>
 <option value="1912">
1912</option>
 <option value="1913">
1913</option>
 <option value="1914">
1914</option>
 <option value="1915">
1915</option>
 <option value="1916">
1916</option>
 <option value="1917">
1917</option>
 <option value="1918">
1918</option>
 <option value="1919">
1919</option>
 <option value="1920">
1920</option>
 <option value="1921">
1921</option>
 <option value="1922">
1922</option>
 <option value="1923">
1923</option>
 <option value="1924">
1924</option>
 <option value="1925">
1925</option>
 <option value="1926">
1926</option>
 <option value="1927">
1927</option>
 <option value="1928">
1928</option>
 <option value="1929">
1929</option>
 <option value="1930">
1930</option>
 <option value="1931">
1931</option>
 <option value="1932">
1932</option>
 <option value="1933">
1933</option>
 <option value="1934">
1934</option>
 <option value="1935">
1935</option>
 <option value="1936">
1936</option>
 <option value="1937">
1937</option>
 <option value="1938">
1938</option>
 <option value="1939">
1939</option>
 <option value="1940">
1940</option>
 <option value="1941">
1941</option>
 <option value="1942">
1942</option>
 <option value="1943">
1943</option>
 <option value="1944">
1944</option>
 <option value="1945">
1945</option>
 <option value="1946">
1946</option>
 <option value="1947">
1947</option>
 <option value="1948">
1948</option>
 <option value="1949">
1949</option>
 <option value="1950">
1950</option>
 <option value="1951">
1951</option>
 <option value="1952">
1952</option>
 <option value="1953">
1953</option>
 <option value="1954">
1954</option>
 <option value="1955">
1955</option>
 <option value="1956">
1956</option>
 <option value="1957">
1957</option>
 <option value="1958">
1958</option>
 <option value="1959">
1959</option>
 <option value="1960">
1960</option>
 <option value="1961">
1961</option>
 <option value="1962">
1962</option>
 <option value="1963">
1963</option>
 <option value="1964">
1964</option>
 <option value="1965">
1965</option>
 <option value="1966">
1966</option>
 <option value="1967">
1967</option>
 <option value="1968">
1968</option>
 <option value="1969">
1969</option>
 <option value="1970">
1970</option>
 <option value="1971">
1971</option>
 <option value="1972">
1972</option>
 <option value="1973">
1973</option>
 <option value="1974">
1974</option>
 <option value="1975">
1975</option>
 <option value="1976">
1976</option>
 <option value="1977">
1977</option>
 <option value="1978">
1978</option>
 <option value="1979">
1979</option>
 <option value="1980">
1980</option>
 <option value="1981">
1981</option>
 <option value="1982">
1982</option>
 <option value="1983">
1983</option>
 <option value="1984">
1984</option>
 <option value="1985">
1985</option>
 <option value="1986">
1986</option>
 <option value="1987">
1987</option>
 <option value="1988">
1988</option>
 <option value="1989">
1989</option>
 <option value="1990">
1990</option>
 <option value="1991">
1991</option>
 <option value="1992">
1992</option>
 <option value="1993">
1993</option>
 <option value="1994">
1994</option>
 <option value="1995">
1995</option>
 <option value="1996">
1996</option>
 <option value="1997">
1997</option>
 <option value="1998">
1998</option>
 <option value="1999">
1999</option>
 <option value="2000">
2000</option>
 <option value="2001">
2001</option>
 <option value="2002">
2002</option>
 <option value="2003">
2003</option>
 <option value="2004">
2004</option>
 <option value="2005">
2005</option>
 <option value="2006">
2006</option>
 <option value="2007">
2007</option>
 <option value="2008">
2008</option>
 <option value="2009">
2009</option>
 <option value="2010">
2010</option>
 <option value="2011">
2011</option>
 <option value="2012">
2012</option>
 <option value="2013">
2013</option>
 <option value="2014">
2014</option>
 <option value="2015">
2015</option>
 <option value="2016">
2016</option>
 <option value="2017">
2017</option>
 <option value="2018">
2018</option>
 <option value="2019" >
2019</option>
 <option value="2020">
2020</option>
 <option value="2021">
2021</option>
 <option value="2022">
2022</option>
 <option value="2023">
2023</option>
 <option value="2024">
2024</option>
 <option value="2025">
2025</option>
 <option value="2026">
2026</option>
 <option value="2027">
2027</option>
 <option value="2028">
2028</option>
 <option value="2029">
2029</option>
 <option value="2030">
2030</option>
 <option value="2031">
2031</option>
 <option value="2032">
2032</option>
 <option value="2033">
2033</option>
 <option value="2034">
2034</option>
 <option value="2035">
2035</option>
 <option value="2036">
2036</option>
 <option value="2037">
2037</option>
 <option value="2038">
2038</option>
 <option value="2039">
2039</option>
 <option value="2040">
2040</option>
 <option value="2041">
2041</option>
 <option value="2042">
2042</option>
 <option value="2043">
2043</option>
 <option value="2044">
2044</option>
 <option value="2045">
2045</option>
 <option value="2046">
2046</option>
 <option value="2047">
2047</option>
 <option value="2048">
2048</option>
 <option value="2049">
2049</option>
 <option value="2050">
2050</option>
 <option value="2051">
2051</option>
 <option value="2052">
2052</option>
 <option value="2053">
2053</option>
 <option value="2054">
2054</option>
 <option value="2055">
2055</option>
 <option value="2056">
2056</option>
 <option value="2057">
2057</option>
 <option value="2058">
2058</option>
 <option value="2059">
2059</option>
 <option value="2060">
2060</option>
 <option value="2061">
2061</option>
 <option value="2062">
2062</option>
 <option value="2063">
2063</option>
 <option value="2064">
2064</option>
 <option value="2065">
2065</option>
 <option value="2066">
2066</option>
 <option value="2067">
2067</option>
 <option value="2068">
2068</option>
 <option value="2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-time_mailru_css_attribute_postfix" style="margin:12px 0;font:inherit">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Hora de la Atención<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-time_mailru_css_attribute_postfix">
<div class="m_-1616745373956918955m_-2655095683506931684ss-datetime-box_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684goog-inline-block_mailru_css_attribute_postfix" dir="ltr" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
<select name="entry.206244955_hour" >
<option value="">
h</option>
<option value="00">
00</option>
 <option value="01">
01</option>
 <option value="02">
02</option>
 <option value="03">
03</option>
 <option value="04">
04</option>
 <option value="05">
05</option>
 <option value="06">
06</option>
 <option value="07">
07</option>
 <option value="08">
08</option>
 <option value="09">
09</option>
 <option value="10">
10</option>
 <option value="11">
11</option>
 <option value="12">
12</option>
 <option value="13">
13</option>
 <option value="14" >
14</option>
 <option value="15">
15</option>
 <option value="16">
16</option>
 <option value="17">
17</option>
 <option value="18">
18</option>
 <option value="19">
19</option>
 <option value="20">
20</option>
 <option value="21">
21</option>
 <option value="22">
22</option>
 <option value="23">
23</option>
</select>
:<select name="entry.206244955_minute" >
<option value="">
min</option>
<option value="00">
00</option>
 <option value="01">
01</option>
 <option value="02">
02</option>
 <option value="03">
03</option>
 <option value="04">
04</option>
 <option value="05">
05</option>
 <option value="06">
06</option>
 <option value="07">
07</option>
 <option value="08">
08</option>
 <option value="09">
09</option>
 <option value="10">
10</option>
 <option value="11">
11</option>
 <option value="12">
12</option>
 <option value="13">
13</option>
 <option value="14">
14</option>
 <option value="15">
15</option>
 <option value="16">
16</option>
 <option value="17">
17</option>
 <option value="18">
18</option>
 <option value="19">
19</option>
 <option value="20">
20</option>
 <option value="21">
21</option>
 <option value="22">
22</option>
 <option value="23">
23</option>
 <option value="24">
24</option>
 <option value="25">
25</option>
 <option value="26">
26</option>
 <option value="27">
27</option>
 <option value="28">
28</option>
 <option value="29">
29</option>
 <option value="30" >
30</option>
 <option value="31">
31</option>
 <option value="32">
32</option>
 <option value="33">
33</option>
 <option value="34">
34</option>
 <option value="35">
35</option>
 <option value="36">
36</option>
 <option value="37">
37</option>
 <option value="38">
38</option>
 <option value="39">
39</option>
 <option value="40">
40</option>
 <option value="41">
41</option>
 <option value="42">
42</option>
 <option value="43">
43</option>
 <option value="44">
44</option>
 <option value="45">
45</option>
 <option value="46">
46</option>
 <option value="47">
47</option>
 <option value="48">
48</option>
 <option value="49">
49</option>
 <option value="50">
50</option>
 <option value="51">
51</option>
 <option value="52">
52</option>
 <option value="53">
53</option>
 <option value="54">
54</option>
 <option value="55">
55</option>
 <option value="56">
56</option>
 <option value="57">
57</option>
 <option value="58">
58</option>
 <option value="59">
59</option>
</select>
<div class="m_-1616745373956918955m_-2655095683506931684ss-datetime-box-spacer_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684goog-inline-block_mailru_css_attribute_postfix" style="height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-select_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<select name="entry.1747608258" id="m_-1616745373956918955m_-2655095683506931684entry_1747608258_mailru_css_attribute_postfix">
<option value="">
</option>
<option value="0" >
0</option>
 <option value="1" >
1</option>
 <option value="2" >
2</option>
 <option value="3" >
3</option>
 <option value="4" >
4</option>
</select>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-scale_mailru_css_attribute_postfix" style="margin:12px 0;overflow-x:auto">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<table border="0" cellpadding="5" cellspacing="0" id="m_-1616745373956918955m_-2655095683506931684entry_1421689035_mailru_css_attribute_postfix">
<tbody>
<tr>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
</td>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
0</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
1</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
2</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
3</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
4</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
5</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
6</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
7</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
8</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
9</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
10</td>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
</td>
</tr>
<tr>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-leftlabel_mailru_css_attribute_postfix" style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class="m_-1616745373956918955m_-2655095683506931684aria-todo_mailru_css_attribute_postfix">
</div>
</td>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="0" id="m_-1616745373956918955m_-2655095683506931684group_1421689035_1_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="1" id="m_-1616745373956918955m_-2655095683506931684group_1421689035_2_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="2" id="m_-1616745373956918955m_-2655095683506931684group_1421689035_3_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="3" id="m_-1616745373956918955m_-2655095683506931684group_1421689035_4_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="4" id="m_-1616745373956918955m_-2655095683506931684group_1421689035_5_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="5" id="m_-1616745373956918955m_-2655095683506931684group_1421689035_6_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="6" id="m_-1616745373956918955m_-2655095683506931684group_1421689035_7_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="7" id="m_-1616745373956918955m_-2655095683506931684group_1421689035_8_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="8" id="m_-1616745373956918955m_-2655095683506931684group_1421689035_9_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="9" id="m_-1616745373956918955m_-2655095683506931684group_1421689035_10_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" value="10" id="m_-1616745373956918955m_-2655095683506931684group_1421689035_11_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-rightlabel_mailru_css_attribute_postfix" style="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="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-scale_mailru_css_attribute_postfix" style="margin:12px 0;overflow-x:auto">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Máximo</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<table border="0" cellpadding="5" cellspacing="0" id="m_-1616745373956918955m_-2655095683506931684entry_1244707512_mailru_css_attribute_postfix">
<tbody>
<tr>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
</td>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
0</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
1</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
2</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
3</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
4</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
5</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
6</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
7</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
8</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
9</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
10</td>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
</td>
</tr>
<tr>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-leftlabel_mailru_css_attribute_postfix" style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class="m_-1616745373956918955m_-2655095683506931684aria-todo_mailru_css_attribute_postfix">
</div>
</td>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="0" id="m_-1616745373956918955m_-2655095683506931684group_1244707512_1_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="1" id="m_-1616745373956918955m_-2655095683506931684group_1244707512_2_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="2" id="m_-1616745373956918955m_-2655095683506931684group_1244707512_3_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="3" id="m_-1616745373956918955m_-2655095683506931684group_1244707512_4_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="4" id="m_-1616745373956918955m_-2655095683506931684group_1244707512_5_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="5" id="m_-1616745373956918955m_-2655095683506931684group_1244707512_6_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="6" id="m_-1616745373956918955m_-2655095683506931684group_1244707512_7_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="7" id="m_-1616745373956918955m_-2655095683506931684group_1244707512_8_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="8" id="m_-1616745373956918955m_-2655095683506931684group_1244707512_9_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="9" id="m_-1616745373956918955m_-2655095683506931684group_1244707512_10_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" value="10" id="m_-1616745373956918955m_-2655095683506931684group_1244707512_11_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-rightlabel_mailru_css_attribute_postfix" style="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="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-scale_mailru_css_attribute_postfix" style="margin:12px 0;overflow-x:auto">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Mínimo</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<table border="0" cellpadding="5" cellspacing="0" id="m_-1616745373956918955m_-2655095683506931684entry_853118630_mailru_css_attribute_postfix">
<tbody>
<tr>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
</td>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
0</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
1</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
2</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
3</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
4</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
5</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
6</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
7</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
8</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
9</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
10</td>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
</td>
</tr>
<tr>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-leftlabel_mailru_css_attribute_postfix" style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class="m_-1616745373956918955m_-2655095683506931684aria-todo_mailru_css_attribute_postfix">
</div>
</td>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="0" id="m_-1616745373956918955m_-2655095683506931684group_853118630_1_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="1" id="m_-1616745373956918955m_-2655095683506931684group_853118630_2_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="2" id="m_-1616745373956918955m_-2655095683506931684group_853118630_3_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="3" id="m_-1616745373956918955m_-2655095683506931684group_853118630_4_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="4" id="m_-1616745373956918955m_-2655095683506931684group_853118630_5_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="5" id="m_-1616745373956918955m_-2655095683506931684group_853118630_6_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="6" id="m_-1616745373956918955m_-2655095683506931684group_853118630_7_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="7" id="m_-1616745373956918955m_-2655095683506931684group_853118630_8_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="8" id="m_-1616745373956918955m_-2655095683506931684group_853118630_9_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="9" id="m_-1616745373956918955m_-2655095683506931684group_853118630_10_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
 <td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-1616745373956918955m_-2655095683506931684ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" value="10" id="m_-1616745373956918955m_-2655095683506931684group_853118630_11_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-radio_mailru_css_attribute_postfix">
</div>
</td>
<td class="m_-1616745373956918955m_-2655095683506931684ss-scalerow_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-rightlabel_mailru_css_attribute_postfix" style="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="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-paragraph-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Anamnesis/Evolución<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
QMT bien tolerada, apetito regular, constipacion intermitente. Sin ganancia de peso significativa. </div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-paragraph-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen Físico<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Enflaquecido, palidez piel y mucosas. RR2T,NAS; MP(+), SRA. Abd BDI, masa epigastrica. EEII pulsos distales (+), sin signos TVP.</div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagnóstico<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Cáncer Gástrico Metastásico </div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-item-required_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-paragraph-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<span class="m_-1616745373956918955m_-2655095683506931684ss-required-asterisk_mailru_css_attribute_postfix" style="color:#c43b1d">
*</span>
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Mantener aporte calórico extra. Analgésica según necesidad. Aumentar ingesta de agua.</div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-paragraph-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Paracetamol, celecoxib, metadona, Omeprazol, domperidona, ursofalk, lactulosa, viadil SOS, dulcolax SOS</div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-date_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha aproximada del Próximo Control con usted</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-date_mailru_css_attribute_postfix">
<div class="m_-1616745373956918955m_-2655095683506931684ss-datetime-box_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684goog-inline-block_mailru_css_attribute_postfix" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name="entry.2063615873_day" class="m_-1616745373956918955m_-2655095683506931684ss-day-dropdown_mailru_css_attribute_postfix" >
<option value="">
Día</option>
<option value="1">
1</option>
 <option value="2">
2</option>
 <option value="3">
3</option>
 <option value="4">
4</option>
 <option value="5">
5</option>
 <option value="6">
6</option>
 <option value="7">
7</option>
 <option value="8">
8</option>
 <option value="9">
9</option>
 <option value="10">
10</option>
 <option value="11">
11</option>
 <option value="12">
12</option>
 <option value="13">
13</option>
 <option value="14">
14</option>
 <option value="15">
15</option>
 <option value="16">
16</option>
 <option value="17">
17</option>
 <option value="18">
18</option>
 <option value="19">
19</option>
 <option value="20">
20</option>
 <option value="21">
21</option>
 <option value="22">
22</option>
 <option value="23" >
23</option>
 <option value="24">
24</option>
 <option value="25">
25</option>
 <option value="26">
26</option>
 <option value="27">
27</option>
 <option value="28">
28</option>
 <option value="29">
29</option>
 <option value="30">
30</option>
 <option value="31">
31</option>
</select>
   <select name="entry.2063615873_month" class="m_-1616745373956918955m_-2655095683506931684ss-month-dropdown_mailru_css_attribute_postfix" >
<option value="">
Mes</option>
<option value="1">
enero</option>
 <option value="2">
febrero</option>
 <option value="3">
marzo</option>
 <option value="4" >
abril</option>
 <option value="5">
mayo</option>
 <option value="6">
junio</option>
 <option value="7">
julio</option>
 <option value="8">
agosto</option>
 <option value="9">
septiembre</option>
 <option value="10">
octubre</option>
 <option value="11">
noviembre</option>
 <option value="12">
diciembre</option>
</select>
 <select name="entry.2063615873_year" >
<option value="">
Año</option>
<option value="1896">
1896</option>
 <option value="1897">
1897</option>
 <option value="1898">
1898</option>
 <option value="1899">
1899</option>
 <option value="1900">
1900</option>
 <option value="1901">
1901</option>
 <option value="1902">
1902</option>
 <option value="1903">
1903</option>
 <option value="1904">
1904</option>
 <option value="1905">
1905</option>
 <option value="1906">
1906</option>
 <option value="1907">
1907</option>
 <option value="1908">
1908</option>
 <option value="1909">
1909</option>
 <option value="1910">
1910</option>
 <option value="1911">
1911</option>
 <option value="1912">
1912</option>
 <option value="1913">
1913</option>
 <option value="1914">
1914</option>
 <option value="1915">
1915</option>
 <option value="1916">
1916</option>
 <option value="1917">
1917</option>
 <option value="1918">
1918</option>
 <option value="1919">
1919</option>
 <option value="1920">
1920</option>
 <option value="1921">
1921</option>
 <option value="1922">
1922</option>
 <option value="1923">
1923</option>
 <option value="1924">
1924</option>
 <option value="1925">
1925</option>
 <option value="1926">
1926</option>
 <option value="1927">
1927</option>
 <option value="1928">
1928</option>
 <option value="1929">
1929</option>
 <option value="1930">
1930</option>
 <option value="1931">
1931</option>
 <option value="1932">
1932</option>
 <option value="1933">
1933</option>
 <option value="1934">
1934</option>
 <option value="1935">
1935</option>
 <option value="1936">
1936</option>
 <option value="1937">
1937</option>
 <option value="1938">
1938</option>
 <option value="1939">
1939</option>
 <option value="1940">
1940</option>
 <option value="1941">
1941</option>
 <option value="1942">
1942</option>
 <option value="1943">
1943</option>
 <option value="1944">
1944</option>
 <option value="1945">
1945</option>
 <option value="1946">
1946</option>
 <option value="1947">
1947</option>
 <option value="1948">
1948</option>
 <option value="1949">
1949</option>
 <option value="1950">
1950</option>
 <option value="1951">
1951</option>
 <option value="1952">
1952</option>
 <option value="1953">
1953</option>
 <option value="1954">
1954</option>
 <option value="1955">
1955</option>
 <option value="1956">
1956</option>
 <option value="1957">
1957</option>
 <option value="1958">
1958</option>
 <option value="1959">
1959</option>
 <option value="1960">
1960</option>
 <option value="1961">
1961</option>
 <option value="1962">
1962</option>
 <option value="1963">
1963</option>
 <option value="1964">
1964</option>
 <option value="1965">
1965</option>
 <option value="1966">
1966</option>
 <option value="1967">
1967</option>
 <option value="1968">
1968</option>
 <option value="1969">
1969</option>
 <option value="1970">
1970</option>
 <option value="1971">
1971</option>
 <option value="1972">
1972</option>
 <option value="1973">
1973</option>
 <option value="1974">
1974</option>
 <option value="1975">
1975</option>
 <option value="1976">
1976</option>
 <option value="1977">
1977</option>
 <option value="1978">
1978</option>
 <option value="1979">
1979</option>
 <option value="1980">
1980</option>
 <option value="1981">
1981</option>
 <option value="1982">
1982</option>
 <option value="1983">
1983</option>
 <option value="1984">
1984</option>
 <option value="1985">
1985</option>
 <option value="1986">
1986</option>
 <option value="1987">
1987</option>
 <option value="1988">
1988</option>
 <option value="1989">
1989</option>
 <option value="1990">
1990</option>
 <option value="1991">
1991</option>
 <option value="1992">
1992</option>
 <option value="1993">
1993</option>
 <option value="1994">
1994</option>
 <option value="1995">
1995</option>
 <option value="1996">
1996</option>
 <option value="1997">
1997</option>
 <option value="1998">
1998</option>
 <option value="1999">
1999</option>
 <option value="2000">
2000</option>
 <option value="2001">
2001</option>
 <option value="2002">
2002</option>
 <option value="2003">
2003</option>
 <option value="2004">
2004</option>
 <option value="2005">
2005</option>
 <option value="2006">
2006</option>
 <option value="2007">
2007</option>
 <option value="2008">
2008</option>
 <option value="2009">
2009</option>
 <option value="2010">
2010</option>
 <option value="2011">
2011</option>
 <option value="2012">
2012</option>
 <option value="2013">
2013</option>
 <option value="2014">
2014</option>
 <option value="2015">
2015</option>
 <option value="2016">
2016</option>
 <option value="2017">
2017</option>
 <option value="2018">
2018</option>
 <option value="2019" >
2019</option>
 <option value="2020">
2020</option>
 <option value="2021">
2021</option>
 <option value="2022">
2022</option>
 <option value="2023">
2023</option>
 <option value="2024">
2024</option>
 <option value="2025">
2025</option>
 <option value="2026">
2026</option>
 <option value="2027">
2027</option>
 <option value="2028">
2028</option>
 <option value="2029">
2029</option>
 <option value="2030">
2030</option>
 <option value="2031">
2031</option>
 <option value="2032">
2032</option>
 <option value="2033">
2033</option>
 <option value="2034">
2034</option>
 <option value="2035">
2035</option>
 <option value="2036">
2036</option>
 <option value="2037">
2037</option>
 <option value="2038">
2038</option>
 <option value="2039">
2039</option>
 <option value="2040">
2040</option>
 <option value="2041">
2041</option>
 <option value="2042">
2042</option>
 <option value="2043">
2043</option>
 <option value="2044">
2044</option>
 <option value="2045">
2045</option>
 <option value="2046">
2046</option>
 <option value="2047">
2047</option>
 <option value="2048">
2048</option>
 <option value="2049">
2049</option>
 <option value="2050">
2050</option>
 <option value="2051">
2051</option>
 <option value="2052">
2052</option>
 <option value="2053">
2053</option>
 <option value="2054">
2054</option>
 <option value="2055">
2055</option>
 <option value="2056">
2056</option>
 <option value="2057">
2057</option>
 <option value="2058">
2058</option>
 <option value="2059">
2059</option>
 <option value="2060">
2060</option>
 <option value="2061">
2061</option>
 <option value="2062">
2062</option>
 <option value="2063">
2063</option>
 <option value="2064">
2064</option>
 <option value="2065">
2065</option>
 <option value="2066">
2066</option>
 <option value="2067">
2067</option>
 <option value="2068">
2068</option>
 <option value="2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-text_mailru_css_attribute_postfix" dir="auto" style="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="m_-1616745373956918955m_-2655095683506931684ss-form-question_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-checkbox_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Derivación a otro Prestador Domiciliario</div>
<div class="m_-1616745373956918955m_-2655095683506931684ss-q-help_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
Sólo llene esta sección si es médico y solicita la visita de otro prestador del equipo</div>
<ul class="m_-1616745373956918955m_-2655095683506931684ss-choices_mailru_css_attribute_postfix" style="list-style:none;padding:0;margin:.5em 0 0">
<li class="m_-1616745373956918955m_-2655095683506931684ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<span class="m_-1616745373956918955m_-2655095683506931684ss-choice-item-control_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block">
<input type="checkbox" name="entry.503039759" value="ENFERMERA" id="m_-1616745373956918955m_-2655095683506931684group_503039759_1_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-checkbox_mailru_css_attribute_postfix">
</span>
<span class="m_-1616745373956918955m_-2655095683506931684ss-choice-label_mailru_css_attribute_postfix">
ENFERMERA</span>
</li>
 <li class="m_-1616745373956918955m_-2655095683506931684ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<span class="m_-1616745373956918955m_-2655095683506931684ss-choice-item-control_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block">
<input type="checkbox" name="entry.503039759" value="TENS" id="m_-1616745373956918955m_-2655095683506931684group_503039759_2_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-checkbox_mailru_css_attribute_postfix">
</span>
<span class="m_-1616745373956918955m_-2655095683506931684ss-choice-label_mailru_css_attribute_postfix">
TENS</span>
</li>
 <li class="m_-1616745373956918955m_-2655095683506931684ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<span class="m_-1616745373956918955m_-2655095683506931684ss-choice-item-control_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block">
<input type="checkbox" name="entry.503039759" value="NUTRICIONISTA" id="m_-1616745373956918955m_-2655095683506931684group_503039759_3_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-checkbox_mailru_css_attribute_postfix">
</span>
<span class="m_-1616745373956918955m_-2655095683506931684ss-choice-label_mailru_css_attribute_postfix">
NUTRICIONISTA</span>
</li>
 <li class="m_-1616745373956918955m_-2655095683506931684ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<span class="m_-1616745373956918955m_-2655095683506931684ss-choice-item-control_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block">
<input type="checkbox" name="entry.503039759" value="KINESIOLOGO" id="m_-1616745373956918955m_-2655095683506931684group_503039759_4_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-checkbox_mailru_css_attribute_postfix">
</span>
<span class="m_-1616745373956918955m_-2655095683506931684ss-choice-label_mailru_css_attribute_postfix">
KINESIOLOGO</span>
</li>
 <li class="m_-1616745373956918955m_-2655095683506931684ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<span class="m_-1616745373956918955m_-2655095683506931684ss-choice-item-control_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block">
<input type="checkbox" name="entry.503039759" value="PSICOLOGO" id="m_-1616745373956918955m_-2655095683506931684group_503039759_5_mailru_css_attribute_postfix" class="m_-1616745373956918955m_-2655095683506931684ss-q-checkbox_mailru_css_attribute_postfix">
</span>
<span class="m_-1616745373956918955m_-2655095683506931684ss-choice-label_mailru_css_attribute_postfix">
PSICOLOGO</span>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class="m_-1616745373956918955m_-2655095683506931684errorbox-good_mailru_css_attribute_postfix">
<div dir="auto" class="m_-1616745373956918955m_-2655095683506931684ss-item_mailru_css_attribute_postfix m_-1616745373956918955m_-2655095683506931684ss-embeddable-object-container_mailru_css_attribute_postfix" style="margin:12px 0;max-width:100%">
<div class="m_-1616745373956918955m_-2655095683506931684ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="m_-1616745373956918955m_-2655095683506931684ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style="text-align:right">
<img class="m_-1616745373956918955m_-2655095683506931684ss-image_mailru_css_attribute_postfix" title="" src="https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style="width:78px;outline:none" alt="Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
</form>
</div>
</div>
</td>
</tr>
<tr height="24px">
</tr>
</tbody>
</table>
</div>
<table align="center" cellpadding="0" cellspacing="0" style="max-width:672px;min-width:154px" width="100%">
<tbody>
<tr height="24px">
<td>
</td>
</tr>
<tr>
<td>
<a href="https://docs.google.com/forms?usp=mail_form_link" style="color:#424242;font-size:13px" target="_blank" rel=" noopener noreferrer" >
Crea tu propio formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br clear="all">
<div>
<br>
</div>
-- <br>
<div dir="ltr" class="m_-1616745373956918955gmail_signature_mailru_css_attribute_postfix" >
<div dir="ltr">
<div>
<div dir="ltr">
Rafael Richard C.<div>
Médico</div>
<div>
Universidad de Chile</div>
<div>
Celular: <span class="js-phone-number">
8-9049047</span>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</form>
</form>
</div>
</div>
							<base target="_self" href="https://e-aj.my.com/" />
	</div>
	</div>
</blockquote>
</BODY>
</HTML>
CgkKPC9kaXY+CgoKPC9ibG9ja3F1b3RlPjwvQk9EWT48L0hUTUw+Cg==----ALT--OYjZmTkmW42rNQ7JRGyuEgozdW9p1DWw1555888704--