<div dir="ltr">
<br>
<br>
<div class="gmail_quote">
<div dir="ltr" class="gmail_attr">
---------- Forwarded message ---------<br>
De: <strong class="gmail_sendername" dir="auto">
Formularios de Google</strong>
 <span dir="ltr">
&lt;<a href="mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: mar., 30 de abr. de 2019 a la(s) 23:45<br>
Subject: Registro de Atención Domiciliaria Oncovida<br>
To:  &lt;<a href="mailto:gise.nunez.pavez@gmail.com">
gise.nunez.pavez@gmail.com</a>
&gt;<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 llenar <a href="https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=mail_form_link" target="_blank">
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">
Estas son tus respuestas:</div>
</td>
</tr>
<tr>
<td>
<div class="m_-8213126172429701859ss-form-container">
<div class="m_-8213126172429701859ss-form-heading">
<h1 class="m_-8213126172429701859ss-form-title" dir="ltr" style="margin:.67em 0">
Registro de Atención Domiciliaria Oncovida</h1>
<div class="m_-8213126172429701859ss-form-desc m_-8213126172429701859ss-no-ignore-whitespace" 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_-8213126172429701859ss-form">
<form method="GET" id="m_-8213126172429701859ss-form" target="_blank">
<br>
<div class="m_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-item-required m_-8213126172429701859ss-text" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859emailAddress">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Dirección de correo electrónico<label for="m_-8213126172429701859emailAddress">
</label>
<span class="m_-8213126172429701859ss-required-asterisk" style="color:#c43b1d">
*</span>
</div>
</label>
<div class="m_-8213126172429701859ss-q-text m_-8213126172429701859ss-printable-text-line" 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:gise.nunez.pavez@gmail.com" target="_blank">
gise.nunez.pavez@gmail.com</a>
</div>
</div>
</div>
</div>
<div class="m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-embeddable-object-container" style="margin:12px 0;max-width:100%">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style="text-align:right">
<img class="m_-8213126172429701859ss-image" title="" src="https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style="width:78px;outline:none" alt="Imagen sin título">
</div>
</div>
</div>
</div>
<br>
 <div class="m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-page-break" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="m_-8213126172429701859ss-page-title" style="padding:0.4em;background-color:#eee">
Identificación del Prestador</h2>
<div class="m_-8213126172429701859ss-page-description m_-8213126172429701859ss-no-ignore-whitespace" 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_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-item-required m_-8213126172429701859ss-text" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_579114469">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for="m_-8213126172429701859itemView.getDomIdToLabel()">
</label>
<span class="m_-8213126172429701859ss-required-asterisk" style="color:#c43b1d">
*</span>
</div>
<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class="m_-8213126172429701859ss-q-text" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Giselle Nuñez</div>
</div>
</div>
</div>
<br>
 <div class="m_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-item-required m_-8213126172429701859ss-text" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_1276273985">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for="m_-8213126172429701859itemView.getDomIdToLabel()">
</label>
<span class="m_-8213126172429701859ss-required-asterisk" style="color:#c43b1d">
*</span>
</div>
<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class="m_-8213126172429701859ss-q-text" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
18375328-2</div>
</div>
</div>
</div>
<br>
 <div class="m_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-item-required m_-8213126172429701859ss-select" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_133691676">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for="m_-8213126172429701859itemView.getDomIdToLabel()">
</label>
<span class="m_-8213126172429701859ss-required-asterisk" style="color:#c43b1d">
*</span>
</div>
<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" 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>
</label>
<select name="entry.133691676" disabled id="m_-8213126172429701859entry_133691676">
<option value="">
</option>
<option value="MEDICO" disabled>
MEDICO</option>
 <option value="ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value="TENS" disabled>
TENS</option>
 <option value="KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value="PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value="NUTRICIONISTA" disabled selected>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class="m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-embeddable-object-container" style="margin:12px 0;max-width:100%">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style="text-align:right">
<img class="m_-8213126172429701859ss-image" title="" src="https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style="width:78px;outline:none" alt="Imagen sin título">
</div>
</div>
</div>
</div>
<br>
 <div class="m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-page-break" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="m_-8213126172429701859ss-page-title" style="padding:0.4em;background-color:#eee">
Identificación del Paciente</h2>
<div class="m_-8213126172429701859ss-page-description m_-8213126172429701859ss-no-ignore-whitespace" 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_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-section-header" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="m_-8213126172429701859ss-section-title" style="background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class="m_-8213126172429701859ss-section-description m_-8213126172429701859ss-no-ignore-whitespace" style="margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word">
</div>
</div>
</div>
</div>
<br>
 <div class="m_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-item-required m_-8213126172429701859ss-text" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_823811303">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for="m_-8213126172429701859itemView.getDomIdToLabel()">
</label>
<span class="m_-8213126172429701859ss-required-asterisk" style="color:#c43b1d">
*</span>
</div>
<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class="m_-8213126172429701859ss-q-text" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
7082327-6</div>
</div>
</div>
</div>
<br>
 <div class="m_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-item-required m_-8213126172429701859ss-text" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_1959365839">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente<label for="m_-8213126172429701859itemView.getDomIdToLabel()">
</label>
<span class="m_-8213126172429701859ss-required-asterisk" style="color:#c43b1d">
*</span>
</div>
<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class="m_-8213126172429701859ss-q-text" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Silvia Hernandez</div>
</div>
</div>
</div>
<br>
 <div class="m_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-item-required m_-8213126172429701859ss-select" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_545002227">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsión<label for="m_-8213126172429701859itemView.getDomIdToLabel()">
</label>
<span class="m_-8213126172429701859ss-required-asterisk" style="color:#c43b1d">
*</span>
</div>
<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name="entry.545002227" disabled id="m_-8213126172429701859entry_545002227">
<option value="">
</option>
<option value="BANMEDICA" disabled selected>
BANMEDICA</option>
 <option value="CAPREDENA" disabled>
CAPREDENA</option>
 <option value="COLMENA" disabled>
COLMENA</option>
 <option value="CONSALUD" disabled>
CONSALUD</option>
 <option value="CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value="DIPRECA" disabled>
DIPRECA</option>
 <option value="FONASA" disabled>
FONASA</option>
 <option value="FUNDACION" disabled>
FUNDACION</option>
 <option value="ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value="NUEVA MASVIDA" disabled>
NUEVA MASVIDA</option>
 <option value="VIDATRES" disabled>
VIDATRES</option>
 <option value="PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class="m_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-item-required m_-8213126172429701859ss-text" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_1900161356">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for="m_-8213126172429701859itemView.getDomIdToLabel()">
</label>
<span class="m_-8213126172429701859ss-required-asterisk" style="color:#c43b1d">
*</span>
</div>
<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class="m_-8213126172429701859ss-q-text" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
San Fernando</div>
</div>
</div>
</div>
<br>
 <div class="m_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-item-required m_-8213126172429701859ss-text" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_1298871758">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for="m_-8213126172429701859itemView.getDomIdToLabel()">
</label>
<span class="m_-8213126172429701859ss-required-asterisk" style="color:#c43b1d">
*</span>
</div>
<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class="m_-8213126172429701859ss-q-text" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
San Fernando</div>
</div>
</div>
</div>
<br>
 <div class="m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-embeddable-object-container" style="margin:12px 0;max-width:100%">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style="text-align:right">
<img class="m_-8213126172429701859ss-image" title="" src="https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style="width:78px;outline:none" alt="Imagen sin título">
</div>
</div>
</div>
</div>
<br>
 <div class="m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-page-break" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="m_-8213126172429701859ss-page-title" style="padding:0.4em;background-color:#eee">
Registro de la Atención Domiciliaria</h2>
<div class="m_-8213126172429701859ss-page-description m_-8213126172429701859ss-no-ignore-whitespace" 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_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-item-required m_-8213126172429701859ss-radio" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_2073233714">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atención<label for="m_-8213126172429701859itemView.getDomIdToLabel()">
</label>
<span class="m_-8213126172429701859ss-required-asterisk" style="color:#c43b1d">
*</span>
</div>
<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class="m_-8213126172429701859ss-choices" style="list-style:none;padding:0;margin:.5em 0 0">
<li class="m_-8213126172429701859ss-choice-item" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class="m_-8213126172429701859ss-choice-item-control m_-8213126172429701859goog-inline-block" style="display:inline-block">
<input type="radio" name="entry.1222378237" disabled checked value="Domicilio" id="m_-8213126172429701859group_1222378237_1" class="m_-8213126172429701859ss-q-radio">
</span>
<span class="m_-8213126172429701859ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class="m_-8213126172429701859ss-choice-item" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class="m_-8213126172429701859ss-choice-item-control m_-8213126172429701859goog-inline-block" style="display:inline-block">
<input type="radio" name="entry.1222378237" disabled value="Ambulatorio" id="m_-8213126172429701859group_1222378237_2" class="m_-8213126172429701859ss-q-radio">
</span>
<span class="m_-8213126172429701859ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class="m_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-item-required m_-8213126172429701859ss-date" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_1705849412">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha de la Atención<label for="m_-8213126172429701859itemView.getDomIdToLabel()">
</label>
<span class="m_-8213126172429701859ss-required-asterisk" style="color:#c43b1d">
*</span>
</div>
<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class="m_-8213126172429701859ss-q-date">
<div class="m_-8213126172429701859ss-datetime-box m_-8213126172429701859goog-inline-block" 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_month" disabled class="m_-8213126172429701859ss-month-dropdown" id="m_-8213126172429701859entry.1705849412_month">
<option value="">
Mes</option>
<option value="1">
enero</option>
 <option value="2">
febrero</option>
 <option value="3">
marzo</option>
 <option value="4" selected>
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_day" disabled class="m_-8213126172429701859ss-day-dropdown" id="m_-8213126172429701859entry.1705849412_day">
<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" selected>
30</option>
 <option value="31">
31<!---->
</option>
</select>
 <select name="entry.1705849412_year" disabled id="m_-8213126172429701859entry.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" selected>
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_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-item-required m_-8213126172429701859ss-time" style="margin:12px 0;font:inherit">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_206244955">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Hora de la Atención<label for="m_-8213126172429701859itemView.getDomIdToLabel()">
</label>
<span class="m_-8213126172429701859ss-required-asterisk" style="color:#c43b1d">
*</span>
</div>
<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class="m_-8213126172429701859ss-q-time">
<div class="m_-8213126172429701859ss-datetime-box m_-8213126172429701859goog-inline-block" 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" disabled id="m_-8213126172429701859entry.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" selected>
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" disabled id="m_-8213126172429701859entry.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" selected>
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_-8213126172429701859ss-datetime-box-spacer m_-8213126172429701859goog-inline-block" style="height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class="m_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-item-required m_-8213126172429701859ss-select" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_1747608258">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for="m_-8213126172429701859itemView.getDomIdToLabel()">
</label>
<span class="m_-8213126172429701859ss-required-asterisk" style="color:#c43b1d">
*</span>
</div>
<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name="entry.1747608258" disabled id="m_-8213126172429701859entry_1747608258">
<option value="">
</option>
<option value="0" disabled>
0</option>
 <option value="1" disabled>
1</option>
 <option value="2" disabled selected>
2</option>
 <option value="3" disabled>
3</option>
 <option value="4" disabled>
4</option>
</select>
</div>
</div>
</div>
<br>
 <div class="m_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-scale" style="margin:12px 0;overflow-x:auto">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_1716090865">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border="0" cellpadding="5" cellspacing="0" id="m_-8213126172429701859entry_1421689035">
<tbody>
<tr>
<td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
</td>
<td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1421689035_1" style="display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1421689035_2" style="display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1421689035_3" style="display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1421689035_4" style="display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <!---->
<td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1421689035_5" style="display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1421689035_6" style="display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1421689035_7" style="display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1421689035_8" style="display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <!---->
<td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1421689035_9" style="display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1421689035_10" style="display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1421689035_11" style="display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
</td>
</tr>
<tr>
<td class="m_-8213126172429701859ss-scalerow m_-8213126172429701859ss-leftlabel" 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_-8213126172429701859aria-todo">
</div>
</td>
<td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
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<input type="radio" name="entry.1421689035" disabled value="0" id="m_-8213126172429701859group_1421689035_1" class="m_-8213126172429701859ss-q-radio">
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</td>
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<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1421689035" disabled value="1" id="m_-8213126172429701859group_1421689035_2" class="m_-8213126172429701859ss-q-radio">
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</td>
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<!---->
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
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</td>
 <td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1421689035" disabled value="3" id="m_-8213126172429701859group_1421689035_4" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
 <td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<!---->
<input type="radio" name="entry.1421689035" disabled value="4" id="m_-8213126172429701859group_1421689035_5" class="m_-8213126172429701859ss-q-radio">
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</td>
 <td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1421689035" disabled value="5" id="m_-8213126172429701859group_1421689035_6" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
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<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1421689035" disabled value="6" id="m_-8213126172429701859group_1421689035_7" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
 <!---->
<td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1421689035" disabled value="7" id="m_-8213126172429701859group_1421689035_8" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
 <td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1421689035" disabled value="8" id="m_-8213126172429701859group_1421689035_9" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
 <td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<!---->
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1421689035" disabled value="9" id="m_-8213126172429701859group_1421689035_10" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
 <td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1421689035" disabled value="10" id="m_-8213126172429701859group_1421689035_11" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
<td class="m_-8213126172429701859ss-scalerow m_-8213126172429701859ss-rightlabel" 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_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-scale" style="margin:12px 0;overflow-x:auto">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_2064050596">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Máximo</div>
<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border="0" cellpadding="5" cellspacing="0" id="m_-8213126172429701859entry_1244707512">
<tbody>
<tr>
<td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
</td>
<td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1244707512_1" style="display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1244707512_2" style="display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1244707512_3" style="display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1244707512_4" style="display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <!---->
<td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1244707512_5" style="display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1244707512_6" style="display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1244707512_7" style="display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1244707512_8" style="display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <!---->
<td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1244707512_9" style="display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1244707512_10" style="display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_1244707512_11" style="display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
</td>
</tr>
<tr>
<td class="m_-8213126172429701859ss-scalerow m_-8213126172429701859ss-leftlabel" 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_-8213126172429701859aria-todo">
</div>
</td>
<td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1244707512" disabled value="0" id="m_-8213126172429701859group_1244707512_1" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
 <td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1244707512" disabled value="1" id="m_-8213126172429701859group_1244707512_2" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
 <td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<!---->
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1244707512" disabled value="2" id="m_-8213126172429701859group_1244707512_3" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
 <td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1244707512" disabled value="3" id="m_-8213126172429701859group_1244707512_4" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
 <td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<!---->
<input type="radio" name="entry.1244707512" disabled value="4" id="m_-8213126172429701859group_1244707512_5" class="m_-8213126172429701859ss-q-radio">
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</td>
 <td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1244707512" disabled value="5" id="m_-8213126172429701859group_1244707512_6" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
 <td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1244707512" disabled value="6" id="m_-8213126172429701859group_1244707512_7" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
 <!---->
<td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1244707512" disabled value="7" id="m_-8213126172429701859group_1244707512_8" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
 <td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1244707512" disabled value="8" id="m_-8213126172429701859group_1244707512_9" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
 <td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<!---->
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1244707512" disabled value="9" id="m_-8213126172429701859group_1244707512_10" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
 <td class="m_-8213126172429701859ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="m_-8213126172429701859ss-scalerow-fieldcell">
<input type="radio" name="entry.1244707512" disabled value="10" id="m_-8213126172429701859group_1244707512_11" class="m_-8213126172429701859ss-q-radio">
</div>
</td>
<td class="m_-8213126172429701859ss-scalerow m_-8213126172429701859ss-rightlabel" 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_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-scale" style="margin:12px 0;overflow-x:auto">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_2000523015">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
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<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border="0" cellpadding="5" cellspacing="0" id="m_-8213126172429701859entry_853118630">
<tbody>
<tr>
<td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
</td>
<td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_853118630_1" style="display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_853118630_2" style="display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_853118630_3" style="display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_853118630_4" style="display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <!---->
<td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_853118630_5" style="display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_853118630_6" style="display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_853118630_7" style="display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_853118630_8" style="display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <!---->
<td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_853118630_9" style="display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_853118630_10" style="display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
<label class="m_-8213126172429701859ss-scalenumber" for="m_-8213126172429701859group_853118630_11" style="display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class="m_-8213126172429701859ss-scalenumbers" style="text-align:center">
</td>
</tr>
<tr>
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Anamnesis/Evolución<label for="m_-8213126172429701859itemView.getDomIdToLabel()">
</label>
<span class="m_-8213126172429701859ss-required-asterisk" style="color:#c43b1d">
*</span>
</div>
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</div>
</label>
<div class="m_-8213126172429701859ss-q-text" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
- Paciente señala que el oncólogo indico 2 ciclos más de quimioterapias, total 10 - Último ciclo de quimioterapia (24/04), correspondiente al ciclo 8- Seguimiento de tratamiento medicamentoso: la paciente señala no seguir al 100% - Síntomas gastrointestinales   * Nauseas (generalmente después de medicamento Xumadol)  * Vomitos (-)  * Diarrea (-)  * Apetito disminuido   * Además presenta dolor en el epigastrio y zona abdominal- Horas de sueño 23:30 hr - 06:00 hr- Actividad física (-) la paciente se encuentra con poco ánimo - Anamnesis alimentaria   * Agua (-), jugo de fruta cocida (1 vaso al día)  * Desayuno --&gt; 07:00 hrs --&gt; té con endulzante acompañado de 1/2 pan con jamón de pavo  * Colación --&gt; 09:30 hrs --&gt; Fruta o Glucerna  * Colación --&gt; 11:30 hrs --&gt; Fruta   * Almuerzo --&gt; 13:30 hrs --&gt; hoy --&gt; Lentejas de verduras, con ensalada de lechuga (solo 2 cucharadas) --&gt; Postre cucharaditas de plátano  * Once --&gt; 17:30 hrs --&gt; Té con endulzante acompañado de 1/2 pan con jamón de pavo o mantequilla o palta  * Cena --&gt; 3 veces a la semana --&gt; 20:00 hrs --&gt; Sopa de verduras con pollo o pavo o clara de huevo- Encuesta de frecuencia de consumo últimas 2 semanas  * Legumbres --&gt; 1/7  * Pescado natural --&gt; 1/7  Pescado en conserva --&gt; (-)  * Frituras (-)  * Embutidos (-)  * Frutas --&gt; 3 veces al día --&gt; 1/2 porción cada vez o menos  * Lácteos (-)  * Huevo --&gt; 3/7  * Vacuno  --&gt; 2/7  * Pollo o pavo --&gt; 3/7  * Cerdo (-)- Evaluación Nutricional   * Peso: 46,7 kg  * Talla : 149 cm  * IMC: 21 kg/m2  * CB: 24,7 cm  * PT: 16,4 mm  * PB: 11 mm  * CMB: 195,8 mm (p5 - p10)  * AMB: 3.052,4 mm2 (p5 - p10)  * AGB: 1.805 mm2 (p5 - p10)  * C. cintura : 73 cm  * Disminución de peso: 600 gr</div>
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Examen Físico<label for="m_-8213126172429701859itemView.getDomIdToLabel()">
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*</span>
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Depleción de masa magra y masa grasa</div>
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Diagnóstico<label for="m_-8213126172429701859itemView.getDomIdToLabel()">
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Paciente adulto de sexo femenino con estado nutricional normal según indicador IMC, con moderada depresión de masa magra y masa grasa.</div>
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Plan de Tratamiento e Indicaciones<label for="m_-8213126172429701859itemView.getDomIdToLabel()">
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- Se indica al paciente tomar medicamentos según tratamiento médico, para así evitar episodios de dolor y disminuir las nauseas durante el día; con el fin de aumentar las porciones de comida de la paciente- No saltar tiempos de comida (desayuno - colación - colación - almuerzo - postre - once - cena)- Reintegrar lácteos descremados sin azúcar (Leche, yogurt, quesillo y postres de leche)- Aumentar consumo de pescado a 2 veces por semana- Incluir en todas las cenas y almuerzos alimentos con buena fuente de proteínas</div>
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Medicamentos Indicados</div>
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Fecha aproximada del Próximo Control con usted</div>
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Mes</option>
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marzo</option>
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abril</option>
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1</option>
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5</option>
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22</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31<!---->
</option>
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Año</option>
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1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
 <!---->
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1929</option>
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1930</option>
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1932</option>
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1948</option>
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1949<!---->
</option>
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1983</option>
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1984</option>
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1994</option>
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1995</option>
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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" selected>
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_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-text" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_74766472">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class="m_-8213126172429701859ss-q-text" 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_-8213126172429701859ss-form-question m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-checkbox" style="margin:12px 0">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class="m_-8213126172429701859ss-q-item-label" for="m_-8213126172429701859entry_1219705969">
<div class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Derivación a otro Prestador Domiciliario</div>
<div class="m_-8213126172429701859ss-q-help m_-8213126172429701859ss-secondary-text" 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>
</label>
<ul class="m_-8213126172429701859ss-choices" style="list-style:none;padding:0;margin:.5em 0 0">
<li class="m_-8213126172429701859ss-choice-item" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class="m_-8213126172429701859ss-choice-item-control m_-8213126172429701859goog-inline-block" style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled value="ENFERMERA" id="m_-8213126172429701859group_503039759_1" class="m_-8213126172429701859ss-q-checkbox">
</span>
<span class="m_-8213126172429701859ss-choice-label">
ENFERMERA</span>
</label>
</li>
 <li class="m_-8213126172429701859ss-choice-item" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class="m_-8213126172429701859ss-choice-item-control m_-8213126172429701859goog-inline-block" style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled value="TENS" id="m_-8213126172429701859group_503039759_2" class="m_-8213126172429701859ss-q-checkbox">
</span>
<span class="m_-8213126172429701859ss-choice-label">
TENS</span>
</label>
</li>
 <li class="m_-8213126172429701859ss-choice-item" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class="m_-8213126172429701859ss-choice-item-control m_-8213126172429701859goog-inline-block" style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled value="NUTRICIONISTA" id="m_-8213126172429701859group_503039759_3" class="m_-8213126172429701859ss-q-checkbox">
</span>
<span class="m_-8213126172429701859ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
 <li class="m_-8213126172429701859ss-choice-item" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class="m_-8213126172429701859ss-choice-item-control m_-8213126172429701859goog-inline-block" style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled value="KINESIOLOGO" id="m_-8213126172429701859group_503039759_4" class="m_-8213126172429701859ss-q-checkbox">
</span>
<span class="m_-8213126172429701859ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
 <li class="m_-8213126172429701859ss-choice-item" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class="m_-8213126172429701859ss-choice-item-control m_-8213126172429701859goog-inline-block" style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled value="PSICOLOGO" id="m_-8213126172429701859group_503039759_5" class="m_-8213126172429701859ss-q-checkbox">
</span>
<span class="m_-8213126172429701859ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class="m_-8213126172429701859errorbox-good">
<div dir="auto" class="m_-8213126172429701859ss-item m_-8213126172429701859ss-embeddable-object-container" style="margin:12px 0;max-width:100%">
<div class="m_-8213126172429701859ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="m_-8213126172429701859ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style="text-align:right">
<img class="m_-8213126172429701859ss-image" title="" src="https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style="width:78px;outline:none" alt="Imagen sin título">
</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">
Crear tu propio Formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br clear="all">
<div>
<br>
</div>
-- <br>
<div dir="ltr" class="gmail_signature" data-smartmail="gmail_signature">
<div dir="ltr">
<div style="text-align:center">
<font face="tahoma, sans-serif" color="#9900ff">
<i>
Giselle de los Ángeles Núñez Pavez </i>
</font>
</div>
<div style="text-align:center">
<font face="tahoma, sans-serif" color="#9900ff">
<i>
Nutricionista</i>
</font>
</div>
<div style="text-align:center">
<font face="tahoma, sans-serif" color="#9900ff">
<i>
Universidad Católica del Maule</i>
</font>
</div>
</div>
</div>
<!---->
</div>
--000000000000c2d4500587cb7593--