<div dir=3D"ltr">
<br>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class==3D"gmail_attr">
---------- Forwarded message ---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Formularios de Google</strong>
 <span dir=3D"ltr">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: mar., 29 ene. 2019 a las 15:01<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:johana.osorio.m@gmail.com">
johana.osorio.m@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_-7165012911992190709ss-form-container">
<div class=3D"m_-7165012911992190709ss-form-heading">
<h1 class=3D"m_-7165012911992190709ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_-7165012911992190709ss-form-desc m_-7165012911992190709ss-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_-7165012911992190709ss-form">
<form method=3D"GET" id=3D"m_-7165012911992190709ss-form" target=3D"_blank">
<br>
<div class=3D"m_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-item-required m_-7165012911992190709ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709emailAddress">
<div class=3D"m_-7165012911992190709ss-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_-7165012911992190709emailAddress">
</label>
<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_-7165012911992190709ss-q-text m_-7165012911992190709ss-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:johana.osorio.m@gmail.com" target=3D"_blank">
johana.osorio.m@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-7165012911992190709ss-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_-7165012911992190709ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-7165012911992190709ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_-7165012911992190709ss-page-description m_-7165012911992190709ss-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_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-item-required m_-7165012911992190709ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_579114469">
<div class=3D"m_-7165012911992190709ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_-7165012911992190709itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7165012911992190709ss-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%">
JOHANA OSORIO</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-item-required m_-7165012911992190709ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_1276273985">
<div class=3D"m_-7165012911992190709ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_-7165012911992190709itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-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_-7165012911992190709ss-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%">
16817426-8</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-item-required m_-7165012911992190709ss-select" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_133691676">
<div class=3D"m_-7165012911992190709ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_-7165012911992190709itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-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_-7165012911992190709entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled selected>
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_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-7165012911992190709ss-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_-7165012911992190709ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-7165012911992190709ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_-7165012911992190709ss-page-description m_-7165012911992190709ss-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_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-7165012911992190709ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_-7165012911992190709ss-section-description m_-7165012911992190709ss-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_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-item-required m_-7165012911992190709ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_823811303">
<div class=3D"m_-7165012911992190709ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_-7165012911992190709itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-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_-7165012911992190709ss-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%">
44921999-7</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-item-required m_-7165012911992190709ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_1959365839">
<div class=3D"m_-7165012911992190709ss-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_-7165012911992190709itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7165012911992190709ss-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%">
MANUEL OLEA</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-item-required m_-7165012911992190709ss-select" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_545002227">
<div class=3D"m_-7165012911992190709ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_-7165012911992190709itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-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_-7165012911992190709entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled selected>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled>
COLMENA</option>
 <option value=3D"CONSALUD" disabled>
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_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-item-required m_-7165012911992190709ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_1900161356">
<div class=3D"m_-7165012911992190709ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_-7165012911992190709itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7165012911992190709ss-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%">
RANCAGUA</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-item-required m_-7165012911992190709ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_1298871758">
<div class=3D"m_-7165012911992190709ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_-7165012911992190709itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7165012911992190709ss-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%">
COLTAUCO</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-7165012911992190709ss-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_-7165012911992190709ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-7165012911992190709ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_-7165012911992190709ss-page-description m_-7165012911992190709ss-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_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-item-required m_-7165012911992190709ss-radio" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_2073233714">
<div class=3D"m_-7165012911992190709ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_-7165012911992190709itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_-7165012911992190709ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-7165012911992190709ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-7165012911992190709ss-choice-item-control m_-7165012911992190709goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_-7165012911992190709group_1222378237_1" class=3D"m_-7165012911992190709ss-q-radio">
</span>
<span class=3D"m_-7165012911992190709ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_-7165012911992190709ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-7165012911992190709ss-choice-item-control m_-7165012911992190709goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_-7165012911992190709group_1222378237_2" class=3D"m_-7165012911992190709ss-q-radio">
</span>
<span class=3D"m_-7165012911992190709ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-item-required m_-7165012911992190709ss-date" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_1705849412">
<div class=3D"m_-7165012911992190709ss-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_-7165012911992190709itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7165012911992190709ss-q-date">
<div class=3D"m_-7165012911992190709ss-datetime-box m_-7165012911992190709goog-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_-7165012911992190709ss-day-dropdown" id=3D"m_-7165012911992190709entry.1705849412_day">
<option value=3D"">
D==C3=ADa</option>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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4</option>
 <option value=3D"5">
5</option>
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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>
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13</option>
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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" selected>
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_-7165012911992190709ss-month-dropdown" id=3D"m_-7165012911992190709entry.1705849412_month">
<option value=3D"">
Mes</option>
<option value=3D"1" selected>
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">
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_-7165012911992190709entry.1705849412_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
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1898</option>
 <option value=3D"1899">
1899</option>
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1900</option>
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1901</option>
 <option value=3D"1902">
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>
 <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>
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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>
 <option value==3D"1950">
1950</option>
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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>
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1966</option>
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1967</option>
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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>
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1991</option>
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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>
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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>
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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_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-item-required m_-7165012911992190709ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_206244955">
<div class=3D"m_-7165012911992190709ss-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_-7165012911992190709itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7165012911992190709ss-q-time">
<div class=3D"m_-7165012911992190709ss-datetime-box m_-7165012911992190709goog-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_-7165012911992190709entry.206244955_hour">
<option value=3D"">
h</option>
<option value=3D"00">
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>
 <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_-7165012911992190709entry.206244955_minute">
<option value=3D"">
min</option>
<option value=3D"00" selected>
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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29</option>
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33</option>
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35</option>
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38</option>
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39</option>
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40</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>
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56</option>
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57</option>
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58</option>
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59</option>
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<div class=3D"m_-7165012911992190709ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_-7165012911992190709itemView.getDomIdToLabel()">
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<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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1</option>
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2</option>
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3</option>
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4</option>
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<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_1716090865">
<div class=3D"m_-7165012911992190709ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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</td>
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0</label>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
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2</label>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1421689035_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
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</td>
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<div class=3D"m_-7165012911992190709ss-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_-7165012911992190709ss-q-help m_-7165012911992190709ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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<tbody>
<tr>
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</td>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-7165012911992190709ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1244707512_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1244707512_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
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9</label>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
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</td>
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</div>
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</div>
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</div>
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</div>
</td>
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</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_2000523015">
<div class=3D"m_-7165012911992190709ss-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_-7165012911992190709ss-q-help m_-7165012911992190709ss-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_-7165012911992190709entry_853118630">
<tbody>
<tr>
<td class=3D"m_-7165012911992190709ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-7165012911992190709ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_853118630_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-7165012911992190709ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_853118630_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_853118630_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_853118630_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_853118630_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for==3D"m_-7165012911992190709group_853118630_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-7165012911992190709ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_853118630_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_853118630_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_853118630_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_853118630_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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<label class=3D"m_-7165012911992190709ss-scalenumber" for=3D"m_-7165012911992190709group_853118630_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-7165012911992190709ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-7165012911992190709ss-scalerow m_-7165012911992190709ss-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_-7165012911992190709aria-todo">
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</div>
</td>
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</div>
</td>
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</div>
</td>
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</div>
</td>
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</div>
</td>
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<div class=3D"m_-7165012911992190709ss-scalerow-fieldcell">
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</div>
</td>
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<div class=3D"m_-7165012911992190709ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"6" id==3D"m_-7165012911992190709group_853118630_7" class=3D"m_-7165012911992190709ss-q-radio">
</div>
</td>
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<div class=3D"m_-7165012911992190709ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"7" id=3D"m_-7165012911992190709group_853118630_8" class=3D"m_-7165012911992190709ss-q-radio">
</div>
</td>
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<div class=3D"m_-7165012911992190709ss-scalerow-fieldcell">
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</div>
</td>
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<div class==3D"m_-7165012911992190709ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"9" id=3D"m_-7165012911992190709group_853118630_10" class=3D"m_-7165012911992190709ss-q-radio">
</div>
</td>
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<div class=3D"m_-7165012911992190709ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.853118630" disabled checked value=3D"10" id=3D"m_-7165012911992190709group_853118630_11" class=3D"m_-7165012911992190709ss-q-radio">
</div>
</td>
<td class=3D"m_-7165012911992190709ss-scalerow m_-7165012911992190709ss-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_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-item-required m_-7165012911992190709ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_2140974612">
<div class=3D"m_-7165012911992190709ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Anamnesis/Evoluci=C3=B3n<label for=3D"m_-7165012911992190709itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7165012911992190709ss-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%">
El paciente se encuentra con mucha somolencia, abundante sudor, se queja bastante de dolor, refiere malestar generalizado no se logra identificar un solo punto de dolor. No logra realizar movimientos voluntarios en extremidad superior derecho. Bastante malestar en pierna derecha mucha dificultad para mover. Escasa actividad muscular en hemicuerpo derecho. Molestias persistentes en zona lumbosacra. La cuidadora refiere que no duerme en las noches. </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-item-required m_-7165012911992190709ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_824006088">
<div class=3D"m_-7165012911992190709ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen F=C3=ADsico<label for=3D"m_-7165012911992190709itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7165012911992190709ss-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%">
Se eval=C3=BAa en posici=C3=B3n decubito supino, extremidad superior izquierda con movilidad normal, extremidad superior derecha con escasa movilidad y actividad muscular. </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-item-required m_-7165012911992190709ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_1690694733">
<div class=3D"m_-7165012911992190709ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_-7165012911992190709itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7165012911992190709ss-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 Ca Pulmonar, estado de inmovilidad</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-item-required m_-7165012911992190709ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_1255665248">
<div class=3D"m_-7165012911992190709ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_-7165012911992190709itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7165012911992190709ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7165012911992190709ss-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%">
movilizaci=C3=B3n masiva y activo/asistida a tolerancia del paciente</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_1648939075">
<div class=3D"m_-7165012911992190709ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7165012911992190709ss-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_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-date" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
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<div class=3D"m_-7165012911992190709ss-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_-7165012911992190709ss-q-help m_-7165012911992190709ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7165012911992190709ss-q-date">
<div class=3D"m_-7165012911992190709ss-datetime-box m_-7165012911992190709goog-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">
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<option value=3D"">
D==C3=ADa</option>
<option value=3D"1">
1</option>
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2</option>
 <option value=3D"3">
3</option>
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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>
 <option value=3D"19">
19</option>
 <option value=3D"20">
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>
 <option value=3D"26">
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=3D"">
Mes</option>
<option value=3D"1" selected>
enero</option>
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febrero</option>
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marzo</option>
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abril</option>
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mayo</option>
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junio</option>
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julio</option>
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agosto</option>
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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=3D"">
A=C3=B1o</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>
 <option value=3D"1918">
1918</option>
 <option value=3D"1919">
1919</option>
 <option value=3D"1920">
1920</option>
 <option value=3D"1921">
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>
 <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>
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1933</option>
 <option value==3D"1934">
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>
 <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>
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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>
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1966</option>
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1967</option>
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1968</option>
 <option value=3D"1969">
1969</option>
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1970</option>
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1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
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>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
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1980</option>
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1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
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1985</option>
 <option value==3D"1986">
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>
 <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>
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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>
 <option value==3D"2014">
2014</option>
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2015</option>
 <option value==3D"2016">
2016</option>
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2017</option>
 <option value==3D"2018">
2018</option>
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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_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_74766472">
<div class=3D"m_-7165012911992190709ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_-7165012911992190709ss-q-help m_-7165012911992190709ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7165012911992190709ss-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_-7165012911992190709ss-form-question m_-7165012911992190709errorbox-good">
<div dir=3D"auto" class=3D"m_-7165012911992190709ss-item m_-7165012911992190709ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_-7165012911992190709ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7165012911992190709ss-q-item-label" for=3D"m_-7165012911992190709entry_1219705969">
<div class=3D"m_-7165012911992190709ss-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_-7165012911992190709ss-q-help m_-7165012911992190709ss-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_-7165012911992190709ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-7165012911992190709ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-7165012911992190709ss-choice-item-control m_-7165012911992190709goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"ENFERMERA" id=3D"m_-7165012911992190709group_503039759_1" class=3D"m_-7165012911992190709ss-q-checkbox">
</span>
<span class=3D"m_-7165012911992190709ss-choice-label">
ENFERMERA</span>
</label>
</li>
 <li class=3D"m_-7165012911992190709ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-7165012911992190709ss-choice-item-control m_-7165012911992190709goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_-7165012911992190709group_503039759_2" class=3D"m_-7165012911992190709ss-q-checkbox">
</span>
<span class=3D"m_-7165012911992190709ss-choice-label">
TENS</span>
</label>
</li>
 <li class=3D"m_-7165012911992190709ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-7165012911992190709ss-choice-item-control m_-7165012911992190709goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id==3D"m_-7165012911992190709group_503039759_3" class=3D"m_-7165012911992190709ss-q-checkbox">
</span>
<span class=3D"m_-7165012911992190709ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
 <li class=3D"m_-7165012911992190709ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-7165012911992190709ss-choice-item-control m_-7165012911992190709goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"KINESIOLOGO" id=3D"m_-7165012911992190709group_503039759_4" class=3D"m_-7165012911992190709ss-q-checkbox">
</span>
<span class=3D"m_-7165012911992190709ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
 <li class=3D"m_-7165012911992190709ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-7165012911992190709ss-choice-item-control m_-7165012911992190709goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"PSICOLOGO" id=3D"m_-7165012911992190709group_503039759_5" class=3D"m_-7165012911992190709ss-q-checkbox">
</span>
<span class=3D"m_-7165012911992190709ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7165012911992190709errorbox-good">
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</h2>
<div style=3D"text-align:right">
<img class=3D"m_-7165012911992190709ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
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Crea tu propio formulario de Google</a>
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