<div dir=3D"ltr">
<br clear=3D"all">
<div>
<div dir=3D"ltr" class=3D"gmail_signature" data-smartmail=3D"gmail_signature">
<div dir=3D"ltr">
<div>
<div dir==3D"ltr">
<div>
<font size=3D"4">
<img src=3D"https://docs.google.com/uc?export=3Ddownload&amp;id=3D1CZ1y5ajpxZHYVQARdKi0pbNJ5IGsl93s&amp;revid=3D0B3qxlh9GeOnuelMreVgyS2s4Njl2YXJhY245SE9QbXA0SW5VPQ">
<br>
</font>
<br>
</div>
</div>
</div>
</div>
</div>
</div>
<br>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class=3D"gmail_attr">
---------- Forwarded message ---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Formularios de Google</strong>
 <span dir=3D"auto">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: lun., 24 de jun. de 2019 a la(s) 17:23<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:carolinaandrea.vsanchez@gmail.com">
carolinaandrea.vsanchez@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Formularios de Google" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing==3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por llenar <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target=3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Estas son tus respuestas:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_1009995512632545186ss-form-container">
<div class=3D"m_1009995512632545186ss-form-heading">
<h1 class=3D"m_1009995512632545186ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_1009995512632545186ss-form-desc m_1009995512632545186ss-no-ignore-whitespace" style=3D"font:inherit;width:99%;margin:0 0 1em;white-space:pre-wrap;word-wrap:break-word">
Este es el sistema de registro de atenciones domiciliarias de Oncovida.   Debe ser llenado por el prestador individual, y debe realizarse un registro por cada visita domiciliaria.   Si usted no es prestador de Oncovida por favor no llene este formulario.   A continuaci=C3=B3n indique su correo electr=C3=B3nico.</div>
</div>
<div class=3D"m_1009995512632545186ss-form">
<form method=3D"GET" id=3D"m_1009995512632545186ss-form" target=3D"_blank">
<br>
<div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-text" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186emailAddress">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Direcci=C3==B3n de correo electr=C3=B3nico<label for=3D"m_1009995512632545186emailAddress">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_1009995512632545186ss-q-text m_1009995512632545186ss-printable-text-line" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
<a href=3D"mailto:carolinaandrea.vsanchez@gmail.com" target=3D"_blank">
carolinaandrea.vsanchez@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_1009995512632545186ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1009995512632545186ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_1009995512632545186ss-page-description m_1009995512632545186ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
Aqu=C3=AD debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-text" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_579114469">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_1009995512632545186itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1009995512632545186ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
carolina Vargas</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-text" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_1276273985">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_1009995512632545186itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_1009995512632545186ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
17528747-7</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-select" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_133691676">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_1009995512632545186itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
Si asisten m=C3=A1s de 1 prestador simult=C3=A1neamente, cada uno debe hacer un registro independiente</div>
</label>
<select name=3D"entry.133691676" disabled id=3D"m_1009995512632545186entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled selected>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_1009995512632545186ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1009995512632545186ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_1009995512632545186ss-page-description m_1009995512632545186ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1009995512632545186ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_1009995512632545186ss-section-description m_1009995512632545186ss-no-ignore-whitespace" style=3D"margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-text" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_823811303">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_1009995512632545186itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_1009995512632545186ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
1879997-9</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-text" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_1959365839">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente<label for=3D"m_1009995512632545186itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1009995512632545186ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Jose Ruiz</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-select" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_545002227">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_1009995512632545186itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.545002227" disabled id=3D"m_1009995512632545186entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled>
COLMENA</option>
 <option value=3D"CONSALUD" disabled selected>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled>
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled>
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-text" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_1900161356">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_1009995512632545186itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1009995512632545186ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Puerto Montt</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-text" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_1298871758">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_1009995512632545186itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1009995512632545186ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Puerto Montt</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_1009995512632545186ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1009995512632545186ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_1009995512632545186ss-page-description m_1009995512632545186ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos de la atenci==C3=B3n domiciliaria</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-radio" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_2073233714">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_1009995512632545186itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_1009995512632545186ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_1009995512632545186ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_1009995512632545186ss-choice-item-control m_1009995512632545186goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_1009995512632545186group_1222378237_1" class=3D"m_1009995512632545186ss-q-radio">
</span>
<span class=3D"m_1009995512632545186ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_1009995512632545186ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_1009995512632545186ss-choice-item-control m_1009995512632545186goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_1009995512632545186group_1222378237_2" class=3D"m_1009995512632545186ss-q-radio">
</span>
<span class=3D"m_1009995512632545186ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-date" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_1705849412">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha de la Atenci=C3=B3n<label for=3D"m_1009995512632545186itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1009995512632545186ss-q-date">
<div class=3D"m_1009995512632545186ss-datetime-box m_1009995512632545186goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name=3D"entry.1705849412_month" disabled class=3D"m_1009995512632545186ss-month-dropdown" id=3D"m_1009995512632545186entry.1705849412_month">
<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
 <option value=3D"2">
febrero</option>
 <option value=3D"3">
marzo</option>
 <option value=3D"4">
abril</option>
 <option value=3D"5">
mayo</option>
 <option value=3D"6" selected>
junio</option>
 <option value=3D"7">
julio</option>
 <option value=3D"8">
agosto</option>
 <option value=3D"9">
septiembre</option>
 <option value=3D"10">
octubre</option>
 <option value=3D"11">
noviembre</option>
 <option value=3D"12">
diciembre</option>
</select>
   <select name=3D"entry.1705849412_day" disabled class=3D"m_1009995512632545186ss-day-dropdown" id=3D"m_1009995512632545186entry.1705849412_day">
<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
 <option value=3D"2">
2</option>
 <option value=3D"3">
3</option>
 <option value=3D"4">
4</option>
 <option value=3D"5">
5</option>
 <option value=3D"6">
6</option>
 <option value=3D"7">
7</option>
 <option value=3D"8">
8</option>
 <option value=3D"9">
9</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value==3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22" selected>
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_1009995512632545186entry.1705849412_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
 <option value=3D"1898">
1898</option>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
1901</option>
 <option value=3D"1902">
1902</option>
 <option value=3D"1903">
1903</option>
 <option value=3D"1904">
1904</option>
 <option value=3D"1905">
1905</option>
 <option value=3D"1906">
1906</option>
 <option value=3D"1907">
1907</option>
 <option value=3D"1908">
1908</option>
 <option value=3D"1909">
1909</option>
 <option value=3D"1910">
1910</option>
 <option value=3D"1911">
1911</option>
 <option value=3D"1912">
1912</option>
 <option value=3D"1913">
1913</option>
 <option value=3D"1914">
1914</option>
 <option value=3D"1915">
1915</option>
 <option value=3D"1916">
1916</option>
 <option value=3D"1917">
1917</option>
 <option value=3D"1918">
1918</option>
 <option value=3D"1919">
1919</option>
 <option value=3D"1920">
1920</option>
 <option value=3D"1921">
1921</option>
 <option value=3D"1922">
1922</option>
 <option value=3D"1923">
1923</option>
 <option value==3D"1924">
1924</option>
 <option value=3D"1925">
1925</option>
 <option value==3D"1926">
1926</option>
 <option value=3D"1927">
1927</option>
 <option value==3D"1928">
1928</option>
 <option value=3D"1929">
1929</option>
 <option value==3D"1930">
1930</option>
 <option value=3D"1931">
1931</option>
 <option value==3D"1932">
1932</option>
 <option value=3D"1933">
1933</option>
 <option value==3D"1934">
1934</option>
 <option value=3D"1935">
1935</option>
 <option value==3D"1936">
1936</option>
 <option value=3D"1937">
1937</option>
 <option value==3D"1938">
1938</option>
 <option value=3D"1939">
1939</option>
 <option value==3D"1940">
1940</option>
 <option value=3D"1941">
1941</option>
 <option value==3D"1942">
1942</option>
 <option value=3D"1943">
1943</option>
 <option value==3D"1944">
1944</option>
 <option value=3D"1945">
1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
1948</option>
 <option value=3D"1949">
1949</option>
 <option value==3D"1950">
1950</option>
 <option value=3D"1951">
1951</option>
 <option value==3D"1952">
1952</option>
 <option value=3D"1953">
1953</option>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
 <option value=3D"1959">
1959</option>
 <option value==3D"1960">
1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
1976</option>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
 <option value==3D"1980">
1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
 <option value=3D"2011">
2011</option>
 <option value==3D"2012">
2012</option>
 <option value=3D"2013">
2013</option>
 <option value==3D"2014">
2014</option>
 <option value=3D"2015">
2015</option>
 <option value==3D"2016">
2016</option>
 <option value=3D"2017">
2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_206244955">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Hora de la Atenci=C3=B3n<label for=3D"m_1009995512632545186itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1009995512632545186ss-q-time">
<div class=3D"m_1009995512632545186ss-datetime-box m_1009995512632545186goog-inline-block" dir=3D"ltr" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
<select name=3D"entry.206244955_hour" disabled id=3D"m_1009995512632545186entry.206244955_hour">
<option value=3D"">
h</option>
<option value=3D"00">
00</option>
 <option value=3D"01">
01</option>
 <option value=3D"02">
02</option>
 <option value=3D"03">
03</option>
 <option value=3D"04">
04</option>
 <option value=3D"05">
05</option>
 <option value=3D"06">
06</option>
 <option value=3D"07">
07</option>
 <option value=3D"08">
08</option>
 <option value=3D"09">
09</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19" selected>
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value==3D"22">
22</option>
 <option value=3D"23">
23</option>
</select>
.<select name=3D"entry.206244955_minute" disabled id=3D"m_1009995512632545186entry.206244955_minute">
<option value=3D"">
min</option>
<option value=3D"00" selected>
00</option>
 <option value=3D"01">
01</option>
 <option value=3D"02">
02</option>
 <option value=3D"03">
03</option>
 <option value=3D"04">
04</option>
 <option value=3D"05">
05</option>
 <option value=3D"06">
06</option>
 <option value=3D"07">
07</option>
 <option value=3D"08">
08</option>
 <option value=3D"09">
09</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value==3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
 <option value=3D"32">
32</option>
 <option value=3D"33">
33</option>
 <option value=3D"34">
34</option>
 <option value=3D"35">
35</option>
 <option value=3D"36">
36</option>
 <option value=3D"37">
37</option>
 <option value=3D"38">
38</option>
 <option value=3D"39">
39</option>
 <option value=3D"40">
40</option>
 <option value=3D"41">
41</option>
 <option value=3D"42">
42</option>
 <option value=3D"43">
43</option>
 <option value=3D"44">
44</option>
 <option value=3D"45">
45</option>
 <option value=3D"46">
46</option>
 <option value=3D"47">
47</option>
 <option value=3D"48">
48</option>
 <option value=3D"49">
49</option>
 <option value=3D"50">
50</option>
 <option value=3D"51">
51</option>
 <option value=3D"52">
52</option>
 <option value=3D"53">
53</option>
 <option value=3D"54">
54</option>
 <option value=3D"55">
55</option>
 <option value=3D"56">
56</option>
 <option value=3D"57">
57</option>
 <option value=3D"58">
58</option>
 <option value=3D"59">
59</option>
</select>
<div class=3D"m_1009995512632545186ss-datetime-box-spacer m_1009995512632545186goog-inline-block" style=3D"height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-select" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_1747608258">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_1009995512632545186itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.1747608258" disabled id=3D"m_1009995512632545186entry_1747608258">
<option value=3D"">
</option>
<option value=3D"0" disabled>
0</option>
 <option value=3D"1" disabled>
1</option>
 <option value=3D"2" disabled selected>
2</option>
 <option value=3D"3" disabled>
3</option>
 <option value=3D"4" disabled>
4</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_1716090865">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_1009995512632545186entry_1421689035">
<tbody>
<tr>
<td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1421689035_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_1009995512632545186ss-scalerow m_1009995512632545186ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_1009995512632545186aria-todo">
</div>
</td>
<td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"0" id=3D"m_1009995512632545186group_1421689035_1" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"1" id=3D"m_1009995512632545186group_1421689035_2" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"2" id=3D"m_1009995512632545186group_1421689035_3" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled checked value=3D"3" id=3D"m_1009995512632545186group_1421689035_4" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name==3D"entry.1421689035" disabled value=3D"4" id=3D"m_1009995512632545186group_1421689035_5" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_1009995512632545186group_1421689035_6" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_1009995512632545186group_1421689035_7" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"7" id=3D"m_1009995512632545186group_1421689035_8" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_1009995512632545186group_1421689035_9" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_1009995512632545186group_1421689035_10" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class==3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name==3D"entry.1421689035" disabled value=3D"10" id=3D"m_1009995512632545186group_1421689035_11" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
<td class=3D"m_1009995512632545186ss-scalerow m_1009995512632545186ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_2064050596">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=A1ximo</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_1009995512632545186entry_1244707512">
<tbody>
<tr>
<td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_1009995512632545186ss-scalerow m_1009995512632545186ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_1009995512632545186aria-todo">
</div>
</td>
<td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"0" id=3D"m_1009995512632545186group_1244707512_1" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"1" id=3D"m_1009995512632545186group_1244707512_2" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"2" id=3D"m_1009995512632545186group_1244707512_3" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"3" id=3D"m_1009995512632545186group_1244707512_4" class==3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"4" id=3D"m_1009995512632545186group_1244707512_5" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled checked value=3D"5" id=3D"m_1009995512632545186group_1244707512_6" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"6" id=3D"m_1009995512632545186group_1244707512_7" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"7" id=3D"m_1009995512632545186group_1244707512_8" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"8" id=3D"m_1009995512632545186group_1244707512_9" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"9" id=3D"m_1009995512632545186group_1244707512_10" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class==3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name==3D"entry.1244707512" disabled value=3D"10" id=3D"m_1009995512632545186group_1244707512_11" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
<td class=3D"m_1009995512632545186ss-scalerow m_1009995512632545186ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_2000523015">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=ADnimo</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_1009995512632545186entry_853118630">
<tbody>
<tr>
<td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_853118630_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for==3D"m_1009995512632545186group_853118630_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_853118630_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_853118630_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class==3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_853118630_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_853118630_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_853118630_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_853118630_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_853118630_9" style==3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_853118630_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1009995512632545186ss-scalenumber" for=3D"m_1009995512632545186group_853118630_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_1009995512632545186ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_1009995512632545186ss-scalerow m_1009995512632545186ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_1009995512632545186aria-todo">
</div>
</td>
<td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"0" id=3D"m_1009995512632545186group_853118630_1" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled checked value=3D"1" id=3D"m_1009995512632545186group_853118630_2" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"2" id=3D"m_1009995512632545186group_853118630_3" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"3" id=3D"m_1009995512632545186group_853118630_4" class==3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"4" id=3D"m_1009995512632545186group_853118630_5" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"5" id=3D"m_1009995512632545186group_853118630_6" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"6" id=3D"m_1009995512632545186group_853118630_7" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"7" id=3D"m_1009995512632545186group_853118630_8" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"8" id=3D"m_1009995512632545186group_853118630_9" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"9" id=3D"m_1009995512632545186group_853118630_10" class=3D"m_1009995512632545186ss-q-radio">
</div>
</td>
 <td class=3D"m_1009995512632545186ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1009995512632545186ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"10" id=3D"m_1009995512632545186group_853118630_11" class==3D"m_1009995512632545186ss-q-radio">
</div>
</td>
<td class=3D"m_1009995512632545186ss-scalerow m_1009995512632545186ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_2140974612">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Anamnesis/Evoluci=C3=B3n<label for=3D"m_1009995512632545186itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1009995512632545186ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Usuario con antecedentes de Ca de pr==C3=B3stata hace mas de 20 a=C3=B1os que completo un ciclo de radioterapia, Alzheimer, ITU recurrente, hospitalizaciones por Neumonia Aspirativa.=20M=C3=A9dico tratante Dr. LagosUsuario en buenas condiciones generales, desorientado en tiempo y espacio, no refiere dolor ni molestias. Familiar manifiesta que presenta dolor en articulaciones, ademas de zona sacra en el periodo de curaciones. Como analgesia Cloxinato de lisina 125 mg via oral, con el cual cede por un tiempo.=20Alimentaci=C3=B3n: Variada, consistencia papillas y l=C3=ADquidos espesos. Nauseas (-) , V=C3=B3mitos (-), en control con nutricionista.Eliminaci=C3=B3n: Sin control de esfinter usa pa=C3=B1ales las 24 horas del d=C3=ADa, diuresis (+) deposiciones (+) sin mayores complicaciones.Movilidad reducida, requiere ayuda para deambular, presenta fatiga y disnea en peque=C3=B1os trayectos, no logra controlar tronco, moviliza extremidades superiores con menos dificultad. Usa colchon antiescara y cojin antiescara, familiares cambian de posici=C3=B3n cada 2 horas.=20Con abundantes secreciones bronquiales, que en ocasiones moviliza y es capaz de eliminarla, con ktr en forma particular.Patr=C3=B3n del sue=C3=B1o con ayuda farmacol=C3=B3gica quetiapina 100 mg al dia.  Logra conciliar y mantener el sue=C3=B1o.Dra. deja como tratamiento acido folico 5 mg y sulfato ferroso 200 mg vo una vez al dia para control de anemia.En curaci=C3=B3n Avanzada por UPP  en zona Sacra grado III por enfermera de convatec, familiar no esta muy conforme con las curaciones, refiere diferencias entre la curaci=C3=B3n particular, ademas de complicaciones por el ap=C3=B3sito secundario debido al uso de pa=C3=B1ales, debo cambiarlo todos los d=C3=ADas, no dejaron insumo para realizar el cambio. </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_824006088">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen F=C3=ADsico<label for=3D"m_1009995512632545186itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1009995512632545186ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Presion Arterial 123/67Pulso 51 x=C2=B4Temperatura 36,5=C2=B0Edema de extremidades inferiores.</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-text" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_1690694733">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_1009995512632545186itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1009995512632545186ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Ca de prostata</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-item-required m_1009995512632545186ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_1255665248">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_1009995512632545186itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1009995512632545186ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1009995512632545186ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Mantener tratamiento indicado por m=C3=A9dicoEn espera de evaluaci=C3=B3n isapre para prestaciones de kinesiologo.Mantener actividades de la vida diaria (comer solo, jugar a las cartas)Realizar ejercicios en extremidades inferiores, caminar trayectos durante el dia.En periodos de descanso extremidades en alto.Valorar caracteristicas del dolor, administrar analgesia indicada por m=C3==A9dico.Refuerzo de aposito secundario cada vez que sea necesario, solicitar a enfermera a cargo.Mantener alimentacion segun indicacion de nutricionista.</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_1648939075">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1009995512632545186ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-date" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_2063615873">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1009995512632545186ss-q-date">
<div class=3D"m_1009995512632545186ss-datetime-box m_1009995512632545186goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name=3D"entry.2063615873_month" disabled class=3D"m_1009995512632545186ss-month-dropdown" id=3D"m_1009995512632545186entry.2063615873_month">
<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
 <option value=3D"2">
febrero</option>
 <option value=3D"3">
marzo</option>
 <option value=3D"4">
abril</option>
 <option value=3D"5">
mayo</option>
 <option value=3D"6" selected>
junio</option>
 <option value=3D"7">
julio</option>
 <option value=3D"8">
agosto</option>
 <option value=3D"9">
septiembre</option>
 <option value=3D"10">
octubre</option>
 <option value=3D"11">
noviembre</option>
 <option value=3D"12">
diciembre</option>
</select>
   <select name=3D"entry.2063615873_day" disabled class=3D"m_1009995512632545186ss-day-dropdown" id=3D"m_1009995512632545186entry.2063615873_day">
<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
 <option value=3D"2">
2</option>
 <option value=3D"3">
3</option>
 <option value=3D"4">
4</option>
 <option value=3D"5">
5</option>
 <option value=3D"6">
6</option>
 <option value=3D"7">
7</option>
 <option value=3D"8">
8</option>
 <option value=3D"9">
9</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value==3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27" selected>
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
</select>
=20<select name=3D"entry.2063615873_year" disabled id=3D"m_1009995512632545186entry.2063615873_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
 <option value=3D"1898">
1898</option>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
1901</option>
 <option value=3D"1902">
1902</option>
 <option value=3D"1903">
1903</option>
 <option value=3D"1904">
1904</option>
 <option value=3D"1905">
1905</option>
 <option value=3D"1906">
1906</option>
 <option value=3D"1907">
1907</option>
 <option value=3D"1908">
1908</option>
 <option value=3D"1909">
1909</option>
 <option value=3D"1910">
1910</option>
 <option value=3D"1911">
1911</option>
 <option value=3D"1912">
1912</option>
 <option value=3D"1913">
1913</option>
 <option value=3D"1914">
1914</option>
 <option value=3D"1915">
1915</option>
 <option value=3D"1916">
1916</option>
 <option value=3D"1917">
1917</option>
 <option value=3D"1918">
1918</option>
 <option value=3D"1919">
1919</option>
 <option value=3D"1920">
1920</option>
 <option value=3D"1921">
1921</option>
 <option value=3D"1922">
1922</option>
 <option value=3D"1923">
1923</option>
 <option value==3D"1924">
1924</option>
 <option value=3D"1925">
1925</option>
 <option value==3D"1926">
1926</option>
 <option value=3D"1927">
1927</option>
 <option value==3D"1928">
1928</option>
 <option value=3D"1929">
1929</option>
 <option value==3D"1930">
1930</option>
 <option value=3D"1931">
1931</option>
 <option value==3D"1932">
1932</option>
 <option value=3D"1933">
1933</option>
 <option value==3D"1934">
1934</option>
 <option value=3D"1935">
1935</option>
 <option value==3D"1936">
1936</option>
 <option value=3D"1937">
1937</option>
 <option value==3D"1938">
1938</option>
 <option value=3D"1939">
1939</option>
 <option value==3D"1940">
1940</option>
 <option value=3D"1941">
1941</option>
 <option value==3D"1942">
1942</option>
 <option value=3D"1943">
1943</option>
 <option value==3D"1944">
1944</option>
 <option value=3D"1945">
1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
1948</option>
 <option value=3D"1949">
1949</option>
 <option value==3D"1950">
1950</option>
 <option value=3D"1951">
1951</option>
 <option value==3D"1952">
1952</option>
 <option value=3D"1953">
1953</option>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
 <option value=3D"1959">
1959</option>
 <option value==3D"1960">
1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
1976</option>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
 <option value==3D"1980">
1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
 <option value=3D"2011">
2011</option>
 <option value==3D"2012">
2012</option>
 <option value=3D"2013">
2013</option>
 <option value==3D"2014">
2014</option>
 <option value=3D"2015">
2015</option>
 <option value==3D"2016">
2016</option>
 <option value=3D"2017">
2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-text" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_74766472">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1009995512632545186ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186ss-form-question m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1009995512632545186ss-q-item-label" for=3D"m_1009995512632545186entry_1219705969">
<div class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_1009995512632545186ss-q-help m_1009995512632545186ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
</label>
<ul class=3D"m_1009995512632545186ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_1009995512632545186ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_1009995512632545186ss-choice-item-control m_1009995512632545186goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"ENFERMERA" id=3D"m_1009995512632545186group_503039759_1" class=3D"m_1009995512632545186ss-q-checkbox">
</span>
<span class=3D"m_1009995512632545186ss-choice-label">
ENFERMERA</span>
</label>
</li>
 <li class=3D"m_1009995512632545186ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_1009995512632545186ss-choice-item-control m_1009995512632545186goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_1009995512632545186group_503039759_2" class=3D"m_1009995512632545186ss-q-checkbox">
</span>
<span class=3D"m_1009995512632545186ss-choice-label">
TENS</span>
</label>
</li>
 <li class=3D"m_1009995512632545186ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_1009995512632545186ss-choice-item-control m_1009995512632545186goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id==3D"m_1009995512632545186group_503039759_3" class=3D"m_1009995512632545186ss-q-checkbox">
</span>
<span class=3D"m_1009995512632545186ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
 <li class=3D"m_1009995512632545186ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_1009995512632545186ss-choice-item-control m_1009995512632545186goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"KINESIOLOGO" id=3D"m_1009995512632545186group_503039759_4" class=3D"m_1009995512632545186ss-q-checkbox">
</span>
<span class=3D"m_1009995512632545186ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
 <li class=3D"m_1009995512632545186ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_1009995512632545186ss-choice-item-control m_1009995512632545186goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"PSICOLOGO" id=3D"m_1009995512632545186group_503039759_5" class=3D"m_1009995512632545186ss-q-checkbox">
</span>
<span class=3D"m_1009995512632545186ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_1009995512632545186errorbox-good">
<div dir=3D"auto" class=3D"m_1009995512632545186ss-item m_1009995512632545186ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_1009995512632545186ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1009995512632545186ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_1009995512632545186ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
</form>
</div>
</div>
</td>
</tr>
<tr height=3D"24px">
</tr>
</tbody>
</table>
</div>
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"max-width:672px;min-width:154px" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242;font-size:13px" target=3D"_blank">
Crear tu propio Formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
--000000000000f4d3d3058c1870ae--