<div dir=3D"ltr">
isabel general talca. por dra nilqger garcia maule..6/8/2019<br>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class=3D"gmail_attr">
---------- Forwarded message ---------<br>
From: <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: Wed, Aug 7, 2019 at 12:40 PM<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:nilqgergarcia@gmail.com">
nilqgergarcia@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 rellenar <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">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_-5200017975724658543ss-form-container">
<div class=3D"m_-5200017975724658543ss-form-heading">
<h1 class=3D"m_-5200017975724658543ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_-5200017975724658543ss-form-desc m_-5200017975724658543ss-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_-5200017975724658543ss-form">
<form method=3D"GET" id=3D"m_-5200017975724658543ss-form" target=3D"_blank">
<br>
<div class=3D"m_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-text" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543emailAddress">
<div class=3D"m_-5200017975724658543ss-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_-5200017975724658543emailAddress">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_-5200017975724658543ss-q-text m_-5200017975724658543ss-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:nilqgergarcia@gmail.com" target=3D"_blank">
nilqgergarcia@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/00-FWRRIiJNpjLIXj1QrTLVceHhiPxWpIN-K4cI0enEtAvmFFnvOHRJTMz5Lq8yFpMHz7WvBnNdiNVchE6Snklpxxc7gIx3OoqTfn_sB2_iSp_6sx7Sr2pww-0pD" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-5200017975724658543ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_-5200017975724658543ss-page-description m_-5200017975724658543ss-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_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-text" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_579114469">
<div class=3D"m_-5200017975724658543ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_-5200017975724658543itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-5200017975724658543ss-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%">
nilqger garcia</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-text" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_1276273985">
<div class=3D"m_-5200017975724658543ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_-5200017975724658543itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-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_-5200017975724658543ss-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%">
25742995-4</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-select" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_133691676">
<div class=3D"m_-5200017975724658543ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_-5200017975724658543itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-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_-5200017975724658543entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled selected>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/mRJInQVKRU12r9blREv2jmlzETLT9JfIHWC0FaeXYfPraPFE9ebBRX8P_hmpfiBP6BNpOgjPBYU0zwBxYxgoLvjQ7EjfjoRTJ2_-8flTaiU_wC008XC8LpcEJ_Yp" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-5200017975724658543ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_-5200017975724658543ss-page-description m_-5200017975724658543ss-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_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-5200017975724658543ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_-5200017975724658543ss-section-description m_-5200017975724658543ss-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_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-text" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_823811303">
<div class=3D"m_-5200017975724658543ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_-5200017975724658543itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-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_-5200017975724658543ss-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%">
7558632-9</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-text" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_1959365839">
<div class=3D"m_-5200017975724658543ss-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_-5200017975724658543itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-5200017975724658543ss-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%">
isabel general</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-select" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_545002227">
<div class=3D"m_-5200017975724658543ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_-5200017975724658543itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-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_-5200017975724658543entry_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_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-text" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_1900161356">
<div class=3D"m_-5200017975724658543ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_-5200017975724658543itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-5200017975724658543ss-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%">
talca</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-text" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_1298871758">
<div class=3D"m_-5200017975724658543ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_-5200017975724658543itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-5200017975724658543ss-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%">
talca</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/URytM0QWRGW_JEL0xQxvOLvwPRJIHyqlnKOm6ky9DRBfzvYVPaAngXV35GNHnaVG-dm9Orno4lr8sy8E-KB9tMrmIhFbVQiOPWy3vUclqRKAJ51dvLdhjBKgXdLO" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-5200017975724658543ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_-5200017975724658543ss-page-description m_-5200017975724658543ss-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_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-radio" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_2073233714">
<div class=3D"m_-5200017975724658543ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_-5200017975724658543itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_-5200017975724658543ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-5200017975724658543ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-5200017975724658543ss-choice-item-control m_-5200017975724658543goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_-5200017975724658543group_1222378237_1" class=3D"m_-5200017975724658543ss-q-radio">
</span>
<span class=3D"m_-5200017975724658543ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_-5200017975724658543ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-5200017975724658543ss-choice-item-control m_-5200017975724658543goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_-5200017975724658543group_1222378237_2" class=3D"m_-5200017975724658543ss-q-radio">
</span>
<span class=3D"m_-5200017975724658543ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-date" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_1705849412">
<div class=3D"m_-5200017975724658543ss-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_-5200017975724658543itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-5200017975724658543ss-q-date">
<div class=3D"m_-5200017975724658543ss-datetime-box m_-5200017975724658543goog-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_day" disabled class=3D"m_-5200017975724658543ss-day-dropdown" id=3D"m_-5200017975724658543entry.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" selected>
6</option>
 <option value=3D"7">
7</option>
 <option value=3D"8">
8</option>
 <option value=3D"9">
9</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value==3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
</select>
   <select name=3D"entry.1705849412_month" disabled class=3D"m_-5200017975724658543ss-month-dropdown" id=3D"m_-5200017975724658543entry.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">
junio</option>
 <option value==3D"7">
julio</option>
 <option value=3D"8" selected>
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>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_-5200017975724658543entry.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_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_206244955">
<div class=3D"m_-5200017975724658543ss-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_-5200017975724658543itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-5200017975724658543ss-q-time">
<div class=3D"m_-5200017975724658543ss-datetime-box m_-5200017975724658543goog-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_-5200017975724658543entry.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">
19</option>
 <option value==3D"20" selected>
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_-5200017975724658543entry.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_-5200017975724658543ss-datetime-box-spacer m_-5200017975724658543goog-inline-block" style=3D"height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-select" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_1747608258">
<div class=3D"m_-5200017975724658543ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_-5200017975724658543itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-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_-5200017975724658543entry_1747608258">
<option value=3D"">
</option>
<option value=3D"0" disabled>
0</option>
 <option value=3D"1" disabled selected>
1</option>
 <option value=3D"2" disabled>
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_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_1716090865">
<div class=3D"m_-5200017975724658543ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-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_-5200017975724658543entry_1421689035">
<tbody>
<tr>
<td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1421689035_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1421689035_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-5200017975724658543ss-scalerow m_-5200017975724658543ss-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_-5200017975724658543aria-todo">
</div>
</td>
<td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled checked value=3D"0" id==3D"m_-5200017975724658543group_1421689035_1" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"1" id=3D"m_-5200017975724658543group_1421689035_2" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"2" id=3D"m_-5200017975724658543group_1421689035_3" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3" id=3D"m_-5200017975724658543group_1421689035_4" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_-5200017975724658543group_1421689035_5" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_-5200017975724658543group_1421689035_6" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_-5200017975724658543group_1421689035_7" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"7" id=3D"m_-5200017975724658543group_1421689035_8" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_-5200017975724658543group_1421689035_9" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_-5200017975724658543group_1421689035_10" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"10" id=3D"m_-5200017975724658543group_1421689035_11" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
<td class=3D"m_-5200017975724658543ss-scalerow m_-5200017975724658543ss-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_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_2064050596">
<div class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-q-help m_-5200017975724658543ss-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_-5200017975724658543entry_1244707512">
<tbody>
<tr>
<td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1244707512_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1244707512_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-5200017975724658543ss-scalerow m_-5200017975724658543ss-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_-5200017975724658543aria-todo">
</div>
</td>
<td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"0" id=3D"m_-5200017975724658543group_1244707512_1" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled checked value=3D"1" id=3D"m_-5200017975724658543group_1244707512_2" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"2" id=3D"m_-5200017975724658543group_1244707512_3" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"3" id=3D"m_-5200017975724658543group_1244707512_4" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"4" id=3D"m_-5200017975724658543group_1244707512_5" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"5" id=3D"m_-5200017975724658543group_1244707512_6" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"6" id=3D"m_-5200017975724658543group_1244707512_7" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"7" id=3D"m_-5200017975724658543group_1244707512_8" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"8" id=3D"m_-5200017975724658543group_1244707512_9" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"9" id=3D"m_-5200017975724658543group_1244707512_10" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"10" id=3D"m_-5200017975724658543group_1244707512_11" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
<td class=3D"m_-5200017975724658543ss-scalerow m_-5200017975724658543ss-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_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_2000523015">
<div class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-q-help m_-5200017975724658543ss-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_-5200017975724658543entry_853118630">
<tbody>
<tr>
<td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_853118630_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_853118630_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_853118630_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_853118630_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_853118630_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for==3D"m_-5200017975724658543group_853118630_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_853118630_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_853118630_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class==3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_853118630_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_853118630_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-5200017975724658543ss-scalenumber" for=3D"m_-5200017975724658543group_853118630_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-5200017975724658543ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-5200017975724658543ss-scalerow m_-5200017975724658543ss-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_-5200017975724658543aria-todo">
</div>
</td>
<td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"0" id=3D"m_-5200017975724658543group_853118630_1" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"1" id=3D"m_-5200017975724658543group_853118630_2" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"2" id=3D"m_-5200017975724658543group_853118630_3" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled checked value=3D"3" id=3D"m_-5200017975724658543group_853118630_4" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class==3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"4" id=3D"m_-5200017975724658543group_853118630_5" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"5" id=3D"m_-5200017975724658543group_853118630_6" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value==3D"6" id=3D"m_-5200017975724658543group_853118630_7" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"7" id=3D"m_-5200017975724658543group_853118630_8" class==3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"8" id=3D"m_-5200017975724658543group_853118630_9" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class==3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"9" id=3D"m_-5200017975724658543group_853118630_10" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
 <td class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"10" id=3D"m_-5200017975724658543group_853118630_11" class=3D"m_-5200017975724658543ss-q-radio">
</div>
</td>
<td class=3D"m_-5200017975724658543ss-scalerow m_-5200017975724658543ss-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_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_2140974612">
<div class=3D"m_-5200017975724658543ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Anamnesis/Evoluci=C3=B3n<label for=3D"m_-5200017975724658543itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-5200017975724658543ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
paciente diagnosticada con c=C3=A1ncer d e colon metast=C3=A1sico sin colostom=C3=ADa, en actual estadiaje quien va a santiago la semana entrante a colocar cat=C3=A9ter d e quimioterapia quien inicia enfermedad actual hace un mes aproximadamente con rectorragia y cl=C3=ADnica d e hemorragia digestiva superior por lo que la ingresan hacen diagnostico y transfunden. paracl=C3=ADnicos reportan adenocarcinoma tubular ulcerado con necrosis extensa en recto, calcio 9.3, alb 3.9, glic 121, hb 8.8, plaquetas 420000. actualmente presenta poca rectorragia eventualmente, un episodio de hematemesis el dia del ingreso, nauseas niega, debilidad, fiebre niega. evacuaciones diarias frecuentes, prurito niega, apetito bueno animo conservado, diuresis conservada. dentro d elos antecedentes de importancia diabetes insulino requiriente en tto con lantus 24 unidades y novorapid, hipertensa en tto, niega alergias. epil=C3=A9ptica en tto.paciente en quimioterapia. dolor eva maximo 4 ptos . se indico buprenorfina 7 mcg/hora cada 3 dias y tramal 10 gotas cada 12 horas. refiere melena eventual.actualmente recibiendo quimioterapia de 5 fluoracilo por bomba de infusi=C3=B3n <a href=3D"http://continua.se" target=3D"_blank">
continua.se</a>
 evidencia ritmo irregularmente irregular durante el examen f=C3=ADsico, con extrasistoles frecuentes, por lo que se supone cardiotoxicidad asociada a la QMT. acude a onc=C3=B2logo medico que la refiere a cardiologo</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_824006088">
<div class=3D"m_-5200017975724658543ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen F=C3=ADsico<label for=3D"m_-5200017975724658543itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-5200017975724658543ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
paciente con palidez cut=C3=A1neo mucosa moderada, pulmonar ruidos respiratorios presentes en ambos campos pulmonares sin agregados, cv ruidos card=C3=ADacos rr=C3=ADtmicos rregulares sin soplos. abdomen blando depresible. 122/85 , fc entre 75 sato2 99 temp 37. aparente buenas condiciones generales, . niega nauseas, v=C3=B3mitos, mareos o disnea u otro s=C3=ADntomas. hemodinamicamente estable</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-text" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_1690694733">
<div class=3D"m_-5200017975724658543ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_-5200017975724658543itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-5200017975724658543ss-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%">
c=C3=A1ncer de colon en estadiaje</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-item-required m_-5200017975724658543ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_1255665248">
<div class=3D"m_-5200017975724658543ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_-5200017975724658543itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-5200017975724658543ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-5200017975724658543ss-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%">
continuar tto medico y acudir a urgencias por arritmia actual de nueva aparicion. control con cardi=C3=B3logo y onc=C3=B3logo m=C3=A9dico</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_1648939075">
<div class=3D"m_-5200017975724658543ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-date" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_2063615873">
<div class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-q-help m_-5200017975724658543ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-5200017975724658543ss-q-date">
<div class=3D"m_-5200017975724658543ss-datetime-box m_-5200017975724658543goog-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_day" disabled class=3D"m_-5200017975724658543ss-day-dropdown" id=3D"m_-5200017975724658543entry.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" selected>
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>
</select>
   <select name=3D"entry.2063615873_month" disabled class=3D"m_-5200017975724658543ss-month-dropdown" id=3D"m_-5200017975724658543entry.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">
junio</option>
 <option value==3D"7">
julio</option>
 <option value=3D"8" selected>
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>
=20<select name=3D"entry.2063615873_year" disabled id=3D"m_-5200017975724658543entry.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_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-text" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_74766472">
<div class=3D"m_-5200017975724658543ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_-5200017975724658543ss-q-help m_-5200017975724658543ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-form-question m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-5200017975724658543ss-q-item-label" for=3D"m_-5200017975724658543entry_1219705969">
<div class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-q-help m_-5200017975724658543ss-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_-5200017975724658543ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-5200017975724658543ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-5200017975724658543ss-choice-item-control m_-5200017975724658543goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"ENFERMERA" id=3D"m_-5200017975724658543group_503039759_1" class=3D"m_-5200017975724658543ss-q-checkbox">
</span>
<span class=3D"m_-5200017975724658543ss-choice-label">
ENFERMERA</span>
</label>
</li>
 <li class=3D"m_-5200017975724658543ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-5200017975724658543ss-choice-item-control m_-5200017975724658543goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_-5200017975724658543group_503039759_2" class=3D"m_-5200017975724658543ss-q-checkbox">
</span>
<span class=3D"m_-5200017975724658543ss-choice-label">
TENS</span>
</label>
</li>
 <li class=3D"m_-5200017975724658543ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-5200017975724658543ss-choice-item-control m_-5200017975724658543goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id==3D"m_-5200017975724658543group_503039759_3" class=3D"m_-5200017975724658543ss-q-checkbox">
</span>
<span class=3D"m_-5200017975724658543ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
 <li class=3D"m_-5200017975724658543ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-5200017975724658543ss-choice-item-control m_-5200017975724658543goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"KINESIOLOGO" id=3D"m_-5200017975724658543group_503039759_4" class=3D"m_-5200017975724658543ss-q-checkbox">
</span>
<span class=3D"m_-5200017975724658543ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
 <li class=3D"m_-5200017975724658543ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-5200017975724658543ss-choice-item-control m_-5200017975724658543goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"PSICOLOGO" id=3D"m_-5200017975724658543group_503039759_5" class=3D"m_-5200017975724658543ss-q-checkbox">
</span>
<span class=3D"m_-5200017975724658543ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-5200017975724658543errorbox-good">
<div dir=3D"auto" class=3D"m_-5200017975724658543ss-item m_-5200017975724658543ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-5200017975724658543ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-5200017975724658543ss-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_-5200017975724658543ss-image" title=3D"" src=3D"https://lh5.googleusercontent.com/Bpur5zPteyG-bXtM-WNRuiLwTi8myvetX7lBkdjzbnQyqUlGcuv84zmWyU3x0Ua2-_WXX9PiJ2cMBOO0zhG2nHX7tXXPHH6_X8UTG8MZzIBwxETkF0a8JyZtuxSL" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</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">
Crea tu propio formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
--000000000000e44fb6058f89a0c6--