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Enviado desde mi smartphone Samsung Galaxy.</div>
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-------- Mensaje original --------</div>
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De: Formularios de Google &lt;forms-receipts-noreply@google.com&gt; </div>
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Fecha: 23/03/2019  9:22  (GMT-03:00) </div>
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Para: franciscasalinas@telemed-chile.cl </div>
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Asunto: Registro de Atención Domiciliaria Oncovida </div>
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<table border="0" cellpadding="0" cellspacing="0" style="background-color:rgb(38,4,154);" width="100%" role="presentation">
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<tr height="64px">
<td style="padding-left: 24px">
<img alt="Formularios de Google" height="26px" style="display: inline-block; margin: 0; vertical-align: middle;" width="143px" src="https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png" id="1553345730726">
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</tbody>
</table>
<div style="padding: 24px; background-color:rgb(229,218,254)">
<div align="center" style="background-color: #fff; border-bottom: 1px solid #e0e0e0; margin: 0 auto; max-width: 624px; min-width: 154px; padding: 0 24px;">
<table align="center" cellpadding="0" cellspacing="0" style="background-color: #fff;" width="100%" role="presentation">
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<tr height="24px">
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<div style="font-size: 13px; line-height: 18px; color: #424242; font-weight: 700">
Gracias por rellenar <a href="https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=mail_form_link">
Registro de Atención Domiciliaria Oncovida</a>
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<div style="font-size: 13px; line-height: 18px; color: #424242;">
Esto es lo que nos has enviado:</div>
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<td>
<div class="ss-form-container" style="">
<div class="ss-form-heading" style="">
<h1 class="ss-form-title" dir="ltr" style="margin:.67em 0;">
Registro de Atención Domiciliaria Oncovida</h1>
<div class="ss-form-desc ss-no-ignore-whitespace" style="font:inherit;width:99%;margin:0 0 1em;white-space:pre-wrap;word-wrap:break-word;">
Este es el sistema de registro de atenciones domiciliarias de Oncovida.   Debe ser llenado por el prestador individual, y debe realizarse un registro por cada visita domiciliaria.   Si usted no es prestador de Oncovida por favor no llene este formulario.   A continuación indique su correo electrónico.</div>
</div>
<div class="ss-form" style="">
<form action="" method="GET" id="ss-form" style="">
<br>
<div class="ss-form-question errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class="ss-q-item-label" for="emailAddress" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Dirección de correo electrónico<label for="emailAddress" aria-label="(Campo obligatorio)" style="">
</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
</label>
<div class="ss-q-text ss-printable-text-line" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
franciscasalinas@telemed-chile.cl</div>
</div>
</div>
</div>
<div class="errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item  ss-embeddable-object-container" style="margin:12px 0;max-width:100%;position:relative;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
</h2>
<div style="text-align: right;">
<img class="ss-image" title="" src="https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style="width: 78px;outline:none;" alt="Imagen sin leyenda" id="1553345730728">
</div>
</div>
</div>
</div>
<br>
 <div class="errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item  ss-page-break" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class="ss-page-title" style="margin:2em -0.4em 0;padding:0.4em;background-color:#eee;">
Identificación del Prestador</h2>
<div class="ss-page-description ss-no-ignore-whitespace" dir="auto" style="white-space:pre-wrap;word-wrap:break-word;">
Aquí debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class="ss-q-item-label" for="entry_579114469" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Primer Nombre y Apellido Paterno<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class="ss-q-text" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Francisca Salinas </div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class="ss-q-item-label" for="entry_1276273985" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
RUT<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class="ss-q-text" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
16765876-8</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item ss-item-required ss-select" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class="ss-q-item-label" for="entry_133691676" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Tipo<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
Si asisten más de 1 prestador simultáneamente, cada uno debe hacer un registro independiente</div>
</label>
<select name="entry.133691676" disabled="" id="entry_133691676" aria-label="Tipo Si asisten más de 1 prestador simultáneamente, cada uno debe hacer un registro independiente " aria-required="true" style="">
<option value="" style="">
</option>
<option value="MEDICO" disabled="" style="">
MEDICO</option>
 <option value="ENFERMERA/O" disabled="" selected="" style="">
ENFERMERA/O</option>
 <option value="TENS" disabled="" style="">
TENS</option>
 <option value="KINESIOLOGA/O" disabled="" style="">
KINESIOLOGA/O</option>
 <option value="PSICOLOGO" disabled="" style="">
PSICOLOGO</option>
 <option value="NUTRICIONISTA" disabled="" style="">
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class="errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item  ss-embeddable-object-container" style="margin:12px 0;max-width:100%;position:relative;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
</h2>
<div style="text-align: right;">
<img class="ss-image" title="" src="https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style="width: 78px;outline:none;" alt="Imagen sin leyenda" id="1553345730728">
</div>
</div>
</div>
</div>
<br>
 <div class="errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item  ss-page-break" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class="ss-page-title" style="margin:2em -0.4em 0;padding:0.4em;background-color:#eee;">
Identificación del Paciente</h2>
<div class="ss-page-description ss-no-ignore-whitespace" dir="auto" style="white-space:pre-wrap;word-wrap:break-word;">
En esta sección debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
 <div class="errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item  ss-section-header" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class="ss-section-title" style="background-color:#eee;padding:0.4em;margin:2em -0.4em 0;">
Datos Personales del Paciente</h2>
<div class="ss-section-description ss-no-ignore-whitespace" style="margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word;">
</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class="ss-q-item-label" for="entry_823811303" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Ingrese el Rut del Paciente<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class="ss-q-text" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
9296192-8</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class="ss-q-item-label" for="entry_1959365839" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Ingrese el Primer Nombre y Apellido Paterno del Paciente<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class="ss-q-text" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Marta de la hoz</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item ss-item-required ss-select" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class="ss-q-item-label" for="entry_545002227" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Previsión<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<select name="entry.545002227" disabled="" id="entry_545002227" aria-label="Previsión  " aria-required="true" style="">
<option value="" style="">
</option>
<option value="BANMEDICA" disabled="" style="">
BANMEDICA</option>
 <option value="CAPREDENA" disabled="" style="">
CAPREDENA</option>
 <option value="COLMENA" disabled="" style="">
COLMENA</option>
 <option value="CONSALUD" disabled="" style="">
CONSALUD</option>
 <option value="CRUZ BLANCA" disabled="" style="">
CRUZ BLANCA</option>
 <option value="DIPRECA" disabled="" selected="" style="">
DIPRECA</option>
 <option value="FONASA" disabled="" style="">
FONASA</option>
 <option value="FUNDACION" disabled="" style="">
FUNDACION</option>
 <option value="ISAPRES DEL COBRE" disabled="" style="">
ISAPRES DEL COBRE</option>
 <option value="NUEVA MASVIDA" disabled="" style="">
NUEVA MASVIDA</option>
 <option value="VIDATRES" disabled="" style="">
VIDATRES</option>
 <option value="PARTICULAR" disabled="" style="">
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class="ss-q-item-label" for="entry_1900161356" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Ciudad<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class="ss-q-text" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Chillán</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class="ss-q-item-label" for="entry_1298871758" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Comuna<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class="ss-q-text" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Chillán</div>
</div>
</div>
</div>
<br>
 <div class="errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item  ss-embeddable-object-container" style="margin:12px 0;max-width:100%;position:relative;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
</h2>
<div style="text-align: right;">
<img class="ss-image" title="" src="https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style="width: 78px;outline:none;" alt="Imagen sin leyenda" id="1553345730729">
</div>
</div>
</div>
</div>
<br>
 <div class="errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item  ss-page-break" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class="ss-page-title" style="margin:2em -0.4em 0;padding:0.4em;background-color:#eee;">
Registro de la Atención Domiciliaria</h2>
<div class="ss-page-description ss-no-ignore-whitespace" dir="auto" style="white-space:pre-wrap;word-wrap:break-word;">
En esta sección debe ingresar los datos de la atención domiciliaria</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item ss-item-required ss-radio" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class="ss-q-item-label" for="entry_2073233714" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Tipo de Atención<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<ul class="ss-choices" role="radiogroup" aria-label="Tipo de Atención  " style="list-style:none;padding:0;margin:.5em 0 0;">
<li class="ss-choice-item" style="margin:0;line-height:1.3em;padding-bottom:.5em;">
<label>
<span class="ss-choice-item-control goog-inline-block" style="position:relative;display:inline-block;">
<input type="radio" name="entry.1222378237" disabled="" checked="" value="Domicilio" id="group_1222378237_1" role="radio" class="ss-q-radio" aria-label="Domicilio" aria-required="true" style="">
</span>
<span class="ss-choice-label" style="">
Domicilio</span>
</label>
</li>
 <li class="ss-choice-item" style="margin:0;line-height:1.3em;padding-bottom:.5em;">
<label>
<span class="ss-choice-item-control goog-inline-block" style="position:relative;display:inline-block;">
<input type="radio" name="entry.1222378237" disabled="" value="Ambulatorio" id="group_1222378237_2" role="radio" class="ss-q-radio" aria-label="Ambulatorio" aria-required="true" style="">
</span>
<span class="ss-choice-label" style="">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item ss-item-required ss-date" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class="ss-q-item-label" for="entry_1705849412" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Fecha de la Atención<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class="ss-q-date" role="group" aria-label="Fecha de la Atención  " style="">
<div class="ss-datetime-box goog-inline-block" role="group" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;position:relative;display:inline-block;">
 <select name="entry.1705849412_day" disabled="" class="ss-day-dropdown" id="entry.1705849412_day" aria-label="Día del mes" aria-required="true" style="">
<option value="" style="">
Día</option>
<option value="1" style="">
1</option>
 <option value="2" style="">
2</option>
 <option value="3" style="">
3</option>
 <option value="4" style="">
4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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<option value="" style="">
Mes</option>
<option value="1" style="">
enero</option>
 <option value="2" style="">
febrero</option>
 <option value="3" selected="" style="">
marzo</option>
 <option value="4" style="">
abril</option>
 <option value="5" style="">
mayo</option>
 <option value="6" style="">
junio</option>
 <option value="7" style="">
julio</option>
 <option value="8" style="">
agosto</option>
 <option value="9" style="">
septiembre</option>
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octubre</option>
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noviembre</option>
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diciembre</option>
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<option value="" style="">
Año</option>
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1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
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2019</option>
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2020</option>
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2021</option>
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2022</option>
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2023</option>
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2024</option>
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2025</option>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
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2032</option>
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2033</option>
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2034</option>
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2035</option>
 <option value="2036" style="">
2036</option>
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2037</option>
 <option value="2038" style="">
2038</option>
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2039</option>
 <option value="2040" style="">
2040</option>
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2041</option>
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2042</option>
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2043</option>
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2044</option>
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2045</option>
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2046</option>
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2047</option>
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2048</option>
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2049</option>
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2050</option>
 <option value="2051" style="">
2051</option>
 <option value="2052" style="">
2052</option>
 <option value="2053" style="">
2053</option>
 <option value="2054" style="">
2054</option>
 <option value="2055" style="">
2055</option>
 <option value="2056" style="">
2056</option>
 <option value="2057" style="">
2057</option>
 <option value="2058" style="">
2058</option>
 <option value="2059" style="">
2059</option>
 <option value="2060" style="">
2060</option>
 <option value="2061" style="">
2061</option>
 <option value="2062" style="">
2062</option>
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2063</option>
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2064</option>
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2065</option>
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2066</option>
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2067</option>
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2068</option>
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2069</option>
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</div>
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</div>
</div>
<br>
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<div dir="auto" class="ss-item ss-item-required ss-time" style="margin:12px 0;font:inherit;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class="ss-q-item-label" for="entry_206244955" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Hora de la Atención<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class="ss-q-time" style="">
<div class="ss-datetime-box goog-inline-block" dir="ltr" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;position:relative;display:inline-block;">
<select name="entry.206244955_hour" disabled="" id="entry.206244955_hour" aria-label="Hora" aria-required="true" style="">
<option value="" style="">
h</option>
<option value="00" style="">
00</option>
 <option value="01" style="">
01</option>
 <option value="02" style="">
02</option>
 <option value="03" style="">
03</option>
 <option value="04" style="">
04</option>
 <option value="05" style="">
05</option>
 <option value="06" style="">
06</option>
 <option value="07" style="">
07</option>
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08</option>
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09</option>
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10</option>
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11</option>
 <option value="12" style="">
12</option>
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13</option>
 <option value="14" style="">
14</option>
 <option value="15" style="">
15</option>
 <option value="16" selected="" style="">
16</option>
 <option value="17" style="">
17</option>
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18</option>
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19</option>
 <option value="20" style="">
20</option>
 <option value="21" style="">
21</option>
 <option value="22" style="">
22</option>
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23</option>
</select>
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<option value="" style="">
min</option>
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00</option>
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01</option>
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02</option>
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03</option>
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04</option>
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05</option>
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06</option>
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07</option>
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08</option>
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09</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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32</option>
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33</option>
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34</option>
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35</option>
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36</option>
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37</option>
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38</option>
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39</option>
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40</option>
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41</option>
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42</option>
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43</option>
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44</option>
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45</option>
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46</option>
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47</option>
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48</option>
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49</option>
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50</option>
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51</option>
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52</option>
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53</option>
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54</option>
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55</option>
 <option value="56" style="">
56</option>
 <option value="57" style="">
57</option>
 <option value="58" style="">
58</option>
 <option value="59" style="">
59</option>
</select>
<div class="ss-datetime-box-spacer goog-inline-block" style="height:32px;vertical-align:middle;position:relative;display:inline-block;">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item ss-item-required ss-select" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class="ss-q-item-label" for="entry_1747608258" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Performance Status ECOG del Paciente<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
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<option value="" style="">
</option>
<option value="0" disabled="" style="">
0</option>
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1</option>
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2</option>
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3</option>
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4</option>
</select>
</div>
</div>
</div>
<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">
<div dir="auto" class="ss-item  ss-scale" style="margin:12px 0;overflow-x:auto;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class="ss-q-item-label" for="entry_1716090865" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Escala Dolor EVA Actual</div>
<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
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</td>
<td class="ss-scalenumbers" style="text-align:center;">
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0</label>
</td>
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<label class="ss-scalenumber" for="group_1421689035_2" style="display:block;padding:0.5em 0 .5em;">
1</label>
</td>
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<label class="ss-scalenumber" for="group_1421689035_3" style="display:block;padding:0.5em 0 .5em;">
2</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_4" style="display:block;padding:0.5em 0 .5em;">
3</label>
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 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_5" style="display:block;padding:0.5em 0 .5em;">
4</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_6" style="display:block;padding:0.5em 0 .5em;">
5</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_7" style="display:block;padding:0.5em 0 .5em;">
6</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_8" style="display:block;padding:0.5em 0 .5em;">
7</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_9" style="display:block;padding:0.5em 0 .5em;">
8</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_10" style="display:block;padding:0.5em 0 .5em;">
9</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_11" style="display:block;padding:0.5em 0 .5em;">
10</label>
</td>
<td class="ss-scalenumbers" style="text-align:center;">
</td>
</tr>
<tr role="radiogroup" aria-label="Escala Dolor EVA Actual  Selecciona un valor en el intervalo de 0 a 10 ." style="">
<td class="ss-scalerow ss-leftlabel" 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" style="">
</div>
</td>
<td class="ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
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<div class="ss-scalerow-fieldcell" style="">
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</div>
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<div dir="auto" class="ss-item  ss-scale" style="margin:12px 0;overflow-x:auto;">
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<label class="ss-q-item-label" for="entry_2064050596" style="">
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Escala Dolor EVA Máximo</div>
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</td>
<td class="ss-scalenumbers" style="text-align:center;">
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0</label>
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<label class="ss-scalenumber" for="group_1244707512_2" style="display:block;padding:0.5em 0 .5em;">
1</label>
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2</label>
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3</label>
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4</label>
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5</label>
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<label class="ss-scalenumber" for="group_1244707512_7" style="display:block;padding:0.5em 0 .5em;">
6</label>
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7</label>
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8</label>
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9</label>
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<label class="ss-scalenumber" for="group_1244707512_11" style="display:block;padding:0.5em 0 .5em;">
10</label>
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</div>
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<br>
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Escala Dolor EVA Mínimo</div>
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1</label>
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4</label>
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5</label>
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6</label>
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7</label>
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8</label>
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9</label>
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10</label>
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<label class="ss-q-item-label" for="entry_2140974612" style="">
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Anamnesis/Evolución<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
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*</span>
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</div>
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Paciente en regulares condiciones generales, consciente, lúcida, orientada, con dolor intenso en estoma. (EVA 10 PUNTOS). Paciebte refiere que este dolor intenso es contínuo, y que aumenta con la salida de materia fecal por la ileostomía, por lo que no se esta alimentando de forma adecuada (disminución considerable de la cantidad y la frecuencia de los alimentos), con el objetivo de reducir la cantidad de materia fecal.</div>
</div>
</div>
</div>
<br>
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<label class="ss-q-item-label" for="entry_824006088" style="">
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Examen Físico<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
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</div>
</label>
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Al examen físico general, paciente en posición decúbito supino, facie de dolor y angustia, piel con presencia de lesiones de tipo dermatitis (brazos, pecho, espalda, piel circundante al estoma, por contacto).- anexos en buenas condiciones.- Estoma de aspecto y coloración normal, con salida de materia fecal (+).- EID: amputación supracondilea. Muñón en buenas condiciones, ya no se encuentra en curaciones. Preparando para la prótesis.Escala de glasgow: 15 puntosEscala de norton: 13 puntosEscala de dowton: 4 puntos</div>
</div>
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</div>
<br>
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<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">
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</div>
</label>
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Ca peritoneal</div>
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Plan de Tratamiento e Indicaciones<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
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*</span>
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- cuidados del estoma. Seguimiento de las indicaciones para dermatitis por contacto. Adecuado aseo de ileostomía.- prevención de caídas.</div>
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Medicamentos Indicados</div>
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- Clobetasol 0.05% 2 veces al día- transtec- Pregabalina 75 mg- duloxetina 30 mg- famotidina 40 mg </div>
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Fecha aproximada del Próximo Control con usted</div>
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5</option>
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25</option>
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26</option>
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27</option>
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28</option>
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30</option>
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31</option>
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1899</option>
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1900</option>
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1901</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1918</option>
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1920</option>
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1929</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1980</option>
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1981</option>
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2018</option>
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2021</option>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2034</option>
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2035</option>
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2036</option>
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2039</option>
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2040</option>
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2041</option>
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2043</option>
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2044</option>
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2045</option>
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2049</option>
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2050</option>
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2054</option>
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2055</option>
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2056</option>
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2057</option>
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2059</option>
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2065</option>
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2066</option>
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2067</option>
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2069</option>
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Tratamiento Realizado (si corresponde)</div>
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Derivación a otro Prestador Domiciliario</div>
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Sólo llene esta sección si es médico y solicita la visita de otro prestador del equipo</div>
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