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<div id="mail-app-auto-signature">
EU Sandra Maulen Ángel<div>
Coordinadora</div>
<div>
Telemed-Chile</div>
</div>
<br>
<br>
-------- Mensaje reenviado --------<br>
De: Dra. IVY ANDREA CONTRERAS VILLAMIZAR &lt;ivycom_villamizar@hotmail.com&gt;<br>
A: coordinadora@telemed-chile.cl &lt;coordinadora@telemed-chile.cl&gt;<br>
Fecha: jueves, 1 de agosto de 2019 20:27 -0400<br>
Asunto: RV: Registro de Atención Domiciliaria Oncovida<br>
<br>
<br>
    <div id="composeWebView_previouse_content" data-mailruapp-compose-id="composeWebView_previouse_content">
<blockquote id="mail-app-auto-quote" style="border-left-width: 1px; border-left-style: solid; border-left-color: rgb(252, 44, 56); margin: 10px 0px 10px 5px; padding: 0px 0px 0px 10px; display: inherit;">
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<b>
De:</b>
 Formularios de Google &lt;<a href="mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;<br>
<b>
Enviado:</b>
 jueves, 1 de agosto de 2019 6:12 p. m.<br>
<b>
Para:</b>
 <a href="mailto:ivycom_villamizar@hotmail.com">
ivycom_villamizar@hotmail.com</a>
 &lt;<a href="mailto:ivycom_villamizar@hotmail.com">
ivycom_villamizar@hotmail.com</a>
&gt;<br>
<b>
Asunto:</b>
 Registro de Atención Domiciliaria Oncovida</font>
<div>
&nbsp;</div>
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<table border="0" cellpadding="0" cellspacing="0" width="100%" role="presentation" style="background-color:rgb(38,4,154)">
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<tr height="64px">
<td style="padding-left:24px">
<img alt="Formularios de Google" height="26px" width="143px" style="display:inline-block;margin:0;vertical-align:middle" 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" width="100%" role="presentation" style="background-color:#fff">
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</td>
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<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" rel=" noopener noreferrer">
Registro de Atención Domiciliaria Oncovida</a>
</div>
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<div style="font-size:13px;line-height:18px;color:#424242">
Estas son tus respuestas:</div>
</td>
</tr>
<tr>
<td>
<div class="ss-form-container_mailru_css_attribute_postfix">
<div class="ss-form-heading_mailru_css_attribute_postfix">
<h1 class="ss-form-title_mailru_css_attribute_postfix" dir="ltr" style="margin:.67em 0">
Registro de Atención Domiciliaria Oncovida</h1>
<div class="ss-form-desc_mailru_css_attribute_postfix ss-no-ignore-whitespace_mailru_css_attribute_postfix" style="font:inherit;width:99%;margin:0 0 1em;white-space:pre-wrap;word-wrap:break-word">
Este es el sistema de registro de atenciones domiciliarias de Oncovida. Debe ser llenado por el prestador individual, y debe realizarse un registro por cada visita domiciliaria. Si usted no es prestador de Oncovida por favor no llene este formulario. A continuación indique su correo electrónico.</div>
</div>
<div class="ss-form_mailru_css_attribute_postfix">
<form id="ss-form_mailru_css_attribute_postfix" target="_blank" action="#" method="POST" onsubmit="return false" rel=" noopener noreferrer">
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Dirección de correo electrónico <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-text_mailru_css_attribute_postfix ss-printable-text-line_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
<a href="mailto:ivycom_villamizar@hotmail.com">
ivycom_villamizar@hotmail.com</a>
</div>
</div>
</div>
</div>
<div class="errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-embeddable-object-container_mailru_css_attribute_postfix" style="margin:12px 0;max-width:100%">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style="text-align:right">
<img class="ss-image_mailru_css_attribute_postfix" title="" alt="Imagen sin título" style="width:78px;outline:none" src="https://lh3.googleusercontent.com/00-FWRRIiJNpjLIXj1QrTLVceHhiPxWpIN-K4cI0enEtAvmFFnvOHRJTMz5Lq8yFpMHz7WvBnNdiNVchE6Snklpxxc7gIx3OoqTfn_sB2_iSp_6sx7Sr2pww-0pD">
</div>
</div>
</div>
</div>
<br>
<div class="errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-page-break_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="ss-page-title_mailru_css_attribute_postfix" style="padding:0.4em;background-color:#eee">
Identificación del Prestador</h2>
<div class="ss-page-description_mailru_css_attribute_postfix ss-no-ignore-whitespace_mailru_css_attribute_postfix" dir="auto" style="white-space:pre-wrap;word-wrap:break-word">
Aquí debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Ivy andrea contreras villamizar</div>
</div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
25923363-1</div>
</div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-select_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
Si asisten más de 1 prestador simultáneamente, cada uno debe hacer un registro independiente</div>
<select name="entry.133691676" disabled="" id="entry_133691676_mailru_css_attribute_postfix" aria-label="Tipo Si asisten más de 1 prestador simultáneamente, cada uno debe hacer un registro independiente">
<option value="">
</option>
 <option value="MEDICO" disabled="" selected="">
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="">
NUTRICIONISTA</option>
</select>
 </div>
</div>
</div>
<br>
<div class="errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-embeddable-object-container_mailru_css_attribute_postfix" style="margin:12px 0;max-width:100%">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style="text-align:right">
<img class="ss-image_mailru_css_attribute_postfix" title="" alt="Imagen sin título" style="width:78px;outline:none" src="https://lh3.googleusercontent.com/mRJInQVKRU12r9blREv2jmlzETLT9JfIHWC0FaeXYfPraPFE9ebBRX8P_hmpfiBP6BNpOgjPBYU0zwBxYxgoLvjQ7EjfjoRTJ2_-8flTaiU_wC008XC8LpcEJ_Yp">
</div>
</div>
</div>
</div>
<br>
<div class="errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-page-break_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="ss-page-title_mailru_css_attribute_postfix" style="padding:0.4em;background-color:#eee">
Identificación del Paciente</h2>
<div class="ss-page-description_mailru_css_attribute_postfix ss-no-ignore-whitespace_mailru_css_attribute_postfix" dir="auto" style="white-space:pre-wrap;word-wrap:break-word">
En esta sección debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
<div class="errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-section-header_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="ss-section-title_mailru_css_attribute_postfix" style="background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class="ss-section-description_mailru_css_attribute_postfix ss-no-ignore-whitespace_mailru_css_attribute_postfix" style="margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word">
</div>
</div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
9103278-3</div>
</div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Serio carrizo oyarce</div>
</div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-select_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsión <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<select name="entry.545002227" disabled="" id="entry_545002227_mailru_css_attribute_postfix" aria-label="Previsión">
<option value="">
</option>
 <option value="BANMEDICA" disabled="">
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="" selected="">
NUEVA MASVIDA</option>
<option value="VIDATRES" disabled="">
VIDATRES</option>
 <option value="PARTICULAR" disabled="">
PARTICULAR</option>
</select>
 </div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Tierra amarilla</div>
</div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Tierra amarilla</div>
</div>
</div>
</div>
<br>
<div class="errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-embeddable-object-container_mailru_css_attribute_postfix" style="margin:12px 0;max-width:100%">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style="text-align:right">
<img class="ss-image_mailru_css_attribute_postfix" title="" alt="Imagen sin título" style="width:78px;outline:none" src="https://lh6.googleusercontent.com/URytM0QWRGW_JEL0xQxvOLvwPRJIHyqlnKOm6ky9DRBfzvYVPaAngXV35GNHnaVG-dm9Orno4lr8sy8E-KB9tMrmIhFbVQiOPWy3vUclqRKAJ51dvLdhjBKgXdLO">
</div>
</div>
</div>
</div>
<br>
<div class="errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-page-break_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="ss-page-title_mailru_css_attribute_postfix" style="padding:0.4em;background-color:#eee">
Registro de la Atención Domiciliaria</h2>
<div class="ss-page-description_mailru_css_attribute_postfix ss-no-ignore-whitespace_mailru_css_attribute_postfix" dir="auto" style="white-space:pre-wrap;word-wrap:break-word">
En esta sección debe ingresar los datos de la atención domiciliaria</div>
</div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-radio_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atención <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<ul class="ss-choices_mailru_css_attribute_postfix" role="radiogroup" aria-label="Tipo de Atención" style="list-style:none;padding:0;margin:.5em 0 0">
<li class="ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<span class="ss-choice-item-control_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block">
<input type="radio" name="entry.1222378237" disabled="" checked="" value="Domicilio" id="group_1222378237_1_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="Domicilio">
</span>
<span class="ss-choice-label_mailru_css_attribute_postfix">
Domicilio</span>
 </li>
<li class="ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<span class="ss-choice-item-control_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block">
<input type="radio" name="entry.1222378237" disabled="" value="Ambulatorio" id="group_1222378237_2_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="Ambulatorio">
</span>
<span class="ss-choice-label_mailru_css_attribute_postfix">
Ambulatorio</span>
 </li>
</ul>
</div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-date_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha de la Atención <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="ss-q-date_mailru_css_attribute_postfix" role="group" aria-label="Fecha de la Atención">
<div class="ss-datetime-box_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" role="group" 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="ss-month-dropdown_mailru_css_attribute_postfix" aria-label="Mes">
<option value="">
Mes</option>
 <option value="1">
enero</option>
 <option value="2">
febrero</option>
 <option value="3">
marzo</option>
 <option value="4">
abril</option>
 <option value="5">
mayo</option>
 <option value="6">
junio</option>
 <option value="7" selected="">
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="ss-day-dropdown_mailru_css_attribute_postfix" aria-label="Día del mes">
<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" selected="">
20</option>
 <option value="21">
21</option>
 <option value="22">
22</option>
 <option value="23">
23</option>
 <option value="24">
24</option>
 <option value="25">
25</option>
<option value="26">
26</option>
 <option value="27">
27</option>
 <option value="28">
28</option>
 <option value="29">
29</option>
 <option value="30">
30</option>
 <option value="31">
31</option>
</select>
 <select name="entry.1705849412_year" disabled="" aria-label="Año">
<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="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-time_mailru_css_attribute_postfix" style="margin:12px 0;font:inherit">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Hora de la Atención <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="ss-q-time_mailru_css_attribute_postfix">
<div class="ss-datetime-box_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" dir="ltr" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
<select name="entry.206244955_hour" disabled="" aria-label="Hora">
<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" selected="">
11</option>
 <option value="12">
12</option>
 <option value="13">
13</option>
 <option value="14">
14</option>
<option value="15">
15</option>
 <option value="16">
16</option>
 <option value="17">
17</option>
 <option value="18">
18</option>
 <option value="19">
19</option>
 <option value="20">
20</option>
 <option value="21">
21</option>
<option value="22">
22</option>
 <option value="23">
23</option>
</select>
 .<select name="entry.206244955_minute" disabled="" aria-label="Minuto">
<option value="">
min</option>
 <option value="00">
00</option>
 <option value="01">
01</option>
 <option value="02">
02</option>
 <option value="03">
03</option>
 <option value="04">
04</option>
 <option value="05">
05</option>
<option value="06">
06</option>
 <option value="07">
07</option>
 <option value="08">
08</option>
 <option value="09">
09</option>
 <option value="10">
10</option>
 <option value="11">
11</option>
 <option value="12">
12</option>
<option value="13">
13</option>
 <option value="14">
14</option>
 <option value="15">
15</option>
 <option value="16">
16</option>
 <option value="17">
17</option>
 <option value="18">
18</option>
 <option value="19">
19</option>
<option value="20">
20</option>
 <option value="21">
21</option>
 <option value="22">
22</option>
 <option value="23">
23</option>
 <option value="24">
24</option>
 <option value="25">
25</option>
 <option value="26">
26</option>
<option value="27">
27</option>
 <option value="28">
28</option>
 <option value="29">
29</option>
 <option value="30" selected="">
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="ss-datetime-box-spacer_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" style="height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-select_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<select name="entry.1747608258" disabled="" id="entry_1747608258_mailru_css_attribute_postfix" aria-label="Performance Status ECOG del Paciente">
<option value="">
</option>
 <option value="0" disabled="">
0</option>
 <option value="1" disabled="" selected="">
1</option>
 <option value="2" disabled="">
2</option>
 <option value="3" disabled="">
3</option>
 <option value="4" disabled="">
4</option>
</select>
 </div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-scale_mailru_css_attribute_postfix" style="margin:12px 0;overflow-x:auto">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual </div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<table border="0" cellpadding="5" cellspacing="0" id="entry_1421689035_mailru_css_attribute_postfix">
<tbody>
<tr aria-hidden="true">
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
0</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
1</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
2</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
3</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
4</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
5</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
6</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
7</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
8</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
9</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
10</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
</td>
</tr>
<tr role="radiogroup" aria-label="Escala Dolor EVA Actual  Selecciona un valor en el rango de 0 a 10.">
<td class="ss-scalerow_mailru_css_attribute_postfix ss-leftlabel_mailru_css_attribute_postfix" style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div aria-hidden="true" class="aria-todo_mailru_css_attribute_postfix">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" disabled="" checked="" value="0" id="group_1421689035_1_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="0">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" disabled="" value="1" id="group_1421689035_2_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="1">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" disabled="" value="2" id="group_1421689035_3_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="2">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" disabled="" value="3" id="group_1421689035_4_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="3">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" disabled="" value="4" id="group_1421689035_5_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="4">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" disabled="" value="5" id="group_1421689035_6_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="5">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" disabled="" value="6" id="group_1421689035_7_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="6">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" disabled="" value="7" id="group_1421689035_8_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="7">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" disabled="" value="8" id="group_1421689035_9_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="8">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" disabled="" value="9" id="group_1421689035_10_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="9">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1421689035" disabled="" value="10" id="group_1421689035_11_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="10">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix ss-rightlabel_mailru_css_attribute_postfix" aria-hidden="true" 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="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-scale_mailru_css_attribute_postfix" style="margin:12px 0;overflow-x:auto">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Máximo </div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<table border="0" cellpadding="5" cellspacing="0" id="entry_1244707512_mailru_css_attribute_postfix">
<tbody>
<tr aria-hidden="true">
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
0</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
1</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
2</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
3</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
4</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
5</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
6</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
7</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
8</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
9</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
10</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
</td>
</tr>
<tr role="radiogroup" aria-label="Escala Dolor EVA Máximo  Selecciona un valor en el rango de 0 a 10.">
<td class="ss-scalerow_mailru_css_attribute_postfix ss-leftlabel_mailru_css_attribute_postfix" style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div aria-hidden="true" class="aria-todo_mailru_css_attribute_postfix">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" disabled="" value="0" id="group_1244707512_1_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="0">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" disabled="" value="1" id="group_1244707512_2_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="1">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" disabled="" value="2" id="group_1244707512_3_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="2">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" disabled="" value="3" id="group_1244707512_4_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="3">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" disabled="" value="4" id="group_1244707512_5_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="4">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" disabled="" value="5" id="group_1244707512_6_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="5">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" disabled="" value="6" id="group_1244707512_7_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="6">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" disabled="" value="7" id="group_1244707512_8_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="7">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" disabled="" value="8" id="group_1244707512_9_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="8">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" disabled="" checked="" value="9" id="group_1244707512_10_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="9">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.1244707512" disabled="" value="10" id="group_1244707512_11_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="10">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix ss-rightlabel_mailru_css_attribute_postfix" aria-hidden="true" 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="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-scale_mailru_css_attribute_postfix" style="margin:12px 0;overflow-x:auto">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Mínimo </div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<table border="0" cellpadding="5" cellspacing="0" id="entry_853118630_mailru_css_attribute_postfix">
<tbody>
<tr aria-hidden="true">
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
0</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
1</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
2</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
3</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
4</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
5</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
6</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
7</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
8</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
9</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
10</td>
<td class="ss-scalenumbers_mailru_css_attribute_postfix" style="text-align:center">
</td>
</tr>
<tr role="radiogroup" aria-label="Escala Dolor EVA Mínimo  Selecciona un valor en el rango de 0 a 10.">
<td class="ss-scalerow_mailru_css_attribute_postfix ss-leftlabel_mailru_css_attribute_postfix" style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div aria-hidden="true" class="aria-todo_mailru_css_attribute_postfix">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" disabled="" checked="" value="0" id="group_853118630_1_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="0">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" disabled="" value="1" id="group_853118630_2_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="1">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" disabled="" value="2" id="group_853118630_3_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="2">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" disabled="" value="3" id="group_853118630_4_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="3">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" disabled="" value="4" id="group_853118630_5_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="4">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" disabled="" value="5" id="group_853118630_6_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="5">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" disabled="" value="6" id="group_853118630_7_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="6">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" disabled="" value="7" id="group_853118630_8_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="7">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" disabled="" value="8" id="group_853118630_9_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="8">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" disabled="" value="9" id="group_853118630_10_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="9">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class="ss-scalerow-fieldcell_mailru_css_attribute_postfix">
<input type="radio" name="entry.853118630" disabled="" value="10" id="group_853118630_11_mailru_css_attribute_postfix" role="radio" class="ss-q-radio_mailru_css_attribute_postfix" aria-label="10">
</div>
</td>
<td class="ss-scalerow_mailru_css_attribute_postfix ss-rightlabel_mailru_css_attribute_postfix" aria-hidden="true" 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="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-paragraph-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Anamnesis/Evolución <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Estable hemodinamicamente, sin cambios su visita anterior.</div>
</div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-paragraph-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen Físico <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Paciente con antecedente de ca gastrico y gastrectomia en el 2018, autovalente actualmente, al examen fisico conciente, orientado, cooperativo, buen estado de animo. Escala de EVA maxkmo de 6 a 8 con episodios de dolor en region abdominal, periumbilical que mejora con tto analgesico. SV: estables TA 123/78 Fr: 18 C/P sin agregados, RcRs. Abdomen blando depresible, hipotrofico en extremidades. SNC sin alteraciones.</div>
</div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagnóstico <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Ca gastrico</div>
</div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-item-required_mailru_css_attribute_postfix ss-paragraph-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones <span class="ss-required-asterisk_mailru_css_attribute_postfix" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Analgesia: tramadol 5 gotas cada 6 horas y SOS, praracetalo 1gr cada 8 horas,pregabalina 150 mg cada 8 horas, glucerna 2 veces dia, powerade 700 ml 1 vez dia, hidraset 3 comprkmidos cada 8h, fokifer 1 disrio. Cloruro de potasio 1 com 600 mg diarios.</div>
</div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-paragraph-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados </div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Ananlesia tramadol 5 gotas cada 6 horas u Sos, paracetamol 1 gr cada 8 horas y mantener medicacion suministros vitamknico y electrolitico, nutricional de basr.</div>
</div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-date_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha aproximada del Próximo Control con usted </div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="ss-q-date_mailru_css_attribute_postfix" role="group" aria-label="Fecha aproximada del Próximo Control con usted">
<div class="ss-datetime-box_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" role="group" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
<select name="entry.2063615873_month" disabled="" class="ss-month-dropdown_mailru_css_attribute_postfix" aria-label="Mes">
<option value="">
Mes</option>
 <option value="1">
enero</option>
 <option value="2">
febrero</option>
 <option value="3">
marzo</option>
 <option value="4">
abril</option>
 <option value="5">
mayo</option>
 <option value="6">
junio</option>
 <option value="7" selected="">
julio</option>
 <option value="8">
agosto</option>
 <option value="9">
septiembre</option>
 <option value="10">
octubre</option>
 <option value="11">
noviembre</option>
 <option value="12">
diciembre</option>
</select>
 <select name="entry.2063615873_day" disabled="" class="ss-day-dropdown_mailru_css_attribute_postfix" aria-label="Día del mes">
<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" selected="">
26</option>
 <option value="27">
27</option>
 <option value="28">
28</option>
 <option value="29">
29</option>
 <option value="30">
30</option>
<option value="31">
31</option>
</select>
 <select name="entry.2063615873_year" disabled="" aria-label="Año">
<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="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-text_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde) </div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
</div>
<div class="ss-q-text_mailru_css_attribute_postfix" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
<div class="ss-form-question_mailru_css_attribute_postfix errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-checkbox_mailru_css_attribute_postfix" style="margin:12px 0">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<div class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Derivación a otro Prestador Domiciliario </div>
<div class="ss-q-help_mailru_css_attribute_postfix ss-secondary-text_mailru_css_attribute_postfix" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666">
Sólo llene esta sección si es médico y solicita la visita de otro prestador del equipo</div>
<ul class="ss-choices_mailru_css_attribute_postfix" role="group" aria-label="Derivación a otro Prestador Domiciliario Sólo llene esta sección si es médico y solicita la visita de otro prestador del equipo" style="list-style:none;padding:0;margin:.5em 0 0">
<li class="ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<span class="ss-choice-item-control_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="" value="ENFERMERA" id="group_503039759_1_mailru_css_attribute_postfix" role="checkbox" class="ss-q-checkbox_mailru_css_attribute_postfix">
</span>
<span class="ss-choice-label_mailru_css_attribute_postfix">
ENFERMERA</span>
 </li>
<li class="ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<span class="ss-choice-item-control_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="" value="TENS" id="group_503039759_2_mailru_css_attribute_postfix" role="checkbox" class="ss-q-checkbox_mailru_css_attribute_postfix">
</span>
<span class="ss-choice-label_mailru_css_attribute_postfix">
TENS</span>
 </li>
<li class="ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<span class="ss-choice-item-control_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="" value="NUTRICIONISTA" id="group_503039759_3_mailru_css_attribute_postfix" role="checkbox" class="ss-q-checkbox_mailru_css_attribute_postfix">
</span>
<span class="ss-choice-label_mailru_css_attribute_postfix">
NUTRICIONISTA</span>
 </li>
<li class="ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<span class="ss-choice-item-control_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="" value="KINESIOLOGO" id="group_503039759_4_mailru_css_attribute_postfix" role="checkbox" class="ss-q-checkbox_mailru_css_attribute_postfix">
</span>
<span class="ss-choice-label_mailru_css_attribute_postfix">
KINESIOLOGO</span>
 </li>
<li class="ss-choice-item_mailru_css_attribute_postfix" style="margin:0;line-height:1.3em;padding-bottom:.5em">
<span class="ss-choice-item-control_mailru_css_attribute_postfix goog-inline-block_mailru_css_attribute_postfix" style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="" value="PSICOLOGO" id="group_503039759_5_mailru_css_attribute_postfix" role="checkbox" class="ss-q-checkbox_mailru_css_attribute_postfix">
</span>
<span class="ss-choice-label_mailru_css_attribute_postfix">
PSICOLOGO</span>
 </li>
</ul>
</div>
</div>
</div>
<br>
<div class="errorbox-good_mailru_css_attribute_postfix" role="listitem">
<div dir="auto" class="ss-item_mailru_css_attribute_postfix ss-embeddable-object-container_mailru_css_attribute_postfix" style="margin:12px 0;max-width:100%">
<div class="ss-form-entry_mailru_css_attribute_postfix" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class="ss-q-title_mailru_css_attribute_postfix" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style="text-align:right">
<img class="ss-image_mailru_css_attribute_postfix" title="" alt="Imagen sin título" style="width:78px;outline:none" src="https://lh5.googleusercontent.com/Bpur5zPteyG-bXtM-WNRuiLwTi8myvetX7lBkdjzbnQyqUlGcuv84zmWyU3x0Ua2-_WXX9PiJ2cMBOO0zhG2nHX7tXXPHH6_X8UTG8MZzIBwxETkF0a8JyZtuxSL">
</div>
</div>
</div>
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<br>
</form>
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<td>
</td>
</tr>
<tr>
<td>
<a href="https://docs.google.com/forms?usp=mail_form_link" style="color:#424242;font-size:13px" target="_blank" rel=" noopener noreferrer">
Crear tu propio Formulario de Google</a>
</td>
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