<div dir=3D"ltr">
Estimada EU Sandra Maul=C3=A9n:<div>
<br>
</div>
<div>
Soy la m=C3=A9dica Viviana Moraga, recientemente incorporada al equipo de trabajo de Telemed Chile</div>
<div>
Hoy realic=C3=A9 mi primera visita domiciliaria a paciente Mar=C3=ADa Ang=C3=A9lica Romero Pino</div>
<div>
Seg=C3=BAn indicaci=C3=B3n de Claudio S=C3=A1ez, reenv=C3=ADo a usted registro de mi atenci==C3=B3n.</div>
<div>
<br>
</div>
<div>
Quedo atenta a cualquier comentario</div>
<div>
Buen d=C3=ADa</div>
<div>
<br>
</div>
<div>
<br>
</div>
<div>
<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">
Google Forms</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: vie., 5 abr. 2019 a las 21:58<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:vivimoragam@gmail.com">
vivimoragam@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"Google Forms" 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">
Thanks for filling out <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">
Here&#39;s what we got from you:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_-2812371870418804589ss-form-container">
<div class=3D"m_-2812371870418804589ss-form-heading">
<h1 class=3D"m_-2812371870418804589ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_-2812371870418804589ss-form-desc m_-2812371870418804589ss-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_-2812371870418804589ss-form">
<form method=3D"GET" id=3D"m_-2812371870418804589ss-form" target=3D"_blank">
<br>
<div class=3D"m_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-item-required m_-2812371870418804589ss-text" style=3D"margin:12px 0">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2812371870418804589ss-q-item-label" for=3D"m_-2812371870418804589emailAddress">
<div class=3D"m_-2812371870418804589ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Email address<label for=3D"m_-2812371870418804589emailAddress">
</label>
<span class=3D"m_-2812371870418804589ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_-2812371870418804589ss-q-text m_-2812371870418804589ss-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:vivimoragam@gmail.com" target=3D"_blank">
vivimoragam@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-2812371870418804589ss-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_-2812371870418804589ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-2812371870418804589ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_-2812371870418804589ss-page-description m_-2812371870418804589ss-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_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-item-required m_-2812371870418804589ss-text" style=3D"margin:12px 0">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2812371870418804589ss-q-item-label" for=3D"m_-2812371870418804589entry_579114469">
<div class=3D"m_-2812371870418804589ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_-2812371870418804589itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2812371870418804589ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2812371870418804589ss-q-help m_-2812371870418804589ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-2812371870418804589ss-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%">
Viviana Moraga</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-item-required m_-2812371870418804589ss-text" style=3D"margin:12px 0">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2812371870418804589ss-q-item-label" for=3D"m_-2812371870418804589entry_1276273985">
<div class=3D"m_-2812371870418804589ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_-2812371870418804589itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2812371870418804589ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2812371870418804589ss-q-help m_-2812371870418804589ss-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_-2812371870418804589ss-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%">
18121502-K</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-item-required m_-2812371870418804589ss-select" style=3D"margin:12px 0">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2812371870418804589ss-q-item-label" for=3D"m_-2812371870418804589entry_133691676">
<div class=3D"m_-2812371870418804589ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_-2812371870418804589itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2812371870418804589ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2812371870418804589ss-q-help m_-2812371870418804589ss-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_-2812371870418804589entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled selected>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-2812371870418804589ss-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_-2812371870418804589ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-2812371870418804589ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_-2812371870418804589ss-page-description m_-2812371870418804589ss-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_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-2812371870418804589ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_-2812371870418804589ss-section-description m_-2812371870418804589ss-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_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-item-required m_-2812371870418804589ss-text" style=3D"margin:12px 0">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2812371870418804589ss-q-item-label" for=3D"m_-2812371870418804589entry_823811303">
<div class=3D"m_-2812371870418804589ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_-2812371870418804589itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2812371870418804589ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2812371870418804589ss-q-help m_-2812371870418804589ss-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_-2812371870418804589ss-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%">
3602556-5</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-item-required m_-2812371870418804589ss-text" style=3D"margin:12px 0">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2812371870418804589ss-q-item-label" for=3D"m_-2812371870418804589entry_1959365839">
<div class=3D"m_-2812371870418804589ss-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_-2812371870418804589itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2812371870418804589ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2812371870418804589ss-q-help m_-2812371870418804589ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-2812371870418804589ss-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%">
Mar=C3=ADa Romero</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-item-required m_-2812371870418804589ss-select" style=3D"margin:12px 0">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2812371870418804589ss-q-item-label" for=3D"m_-2812371870418804589entry_545002227">
<div class=3D"m_-2812371870418804589ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_-2812371870418804589itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2812371870418804589ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2812371870418804589ss-q-help m_-2812371870418804589ss-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_-2812371870418804589entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
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COLMENA</option>
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CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
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DIPRECA</option>
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FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
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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_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-item-required m_-2812371870418804589ss-text" style=3D"margin:12px 0">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2812371870418804589ss-q-item-label" for=3D"m_-2812371870418804589entry_1900161356">
<div class=3D"m_-2812371870418804589ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_-2812371870418804589itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2812371870418804589ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2812371870418804589ss-q-help m_-2812371870418804589ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-2812371870418804589ss-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%">
Concepci=C3=B3n</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-item-required m_-2812371870418804589ss-text" style=3D"margin:12px 0">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2812371870418804589ss-q-item-label" for=3D"m_-2812371870418804589entry_1298871758">
<div class=3D"m_-2812371870418804589ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_-2812371870418804589itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2812371870418804589ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2812371870418804589ss-q-help m_-2812371870418804589ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-2812371870418804589ss-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%">
Concepci=C3=B3n</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-2812371870418804589ss-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_-2812371870418804589ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-2812371870418804589ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_-2812371870418804589ss-page-description m_-2812371870418804589ss-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_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-item-required m_-2812371870418804589ss-radio" style=3D"margin:12px 0">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2812371870418804589ss-q-item-label" for=3D"m_-2812371870418804589entry_2073233714">
<div class=3D"m_-2812371870418804589ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_-2812371870418804589itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2812371870418804589ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2812371870418804589ss-q-help m_-2812371870418804589ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_-2812371870418804589ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-2812371870418804589ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-2812371870418804589ss-choice-item-control m_-2812371870418804589goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_-2812371870418804589group_1222378237_1" class=3D"m_-2812371870418804589ss-q-radio">
</span>
<span class=3D"m_-2812371870418804589ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_-2812371870418804589ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-2812371870418804589ss-choice-item-control m_-2812371870418804589goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_-2812371870418804589group_1222378237_2" class=3D"m_-2812371870418804589ss-q-radio">
</span>
<span class=3D"m_-2812371870418804589ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-item-required m_-2812371870418804589ss-date" style=3D"margin:12px 0">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2812371870418804589ss-q-item-label" for=3D"m_-2812371870418804589entry_1705849412">
<div class=3D"m_-2812371870418804589ss-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_-2812371870418804589itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2812371870418804589ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2812371870418804589ss-q-help m_-2812371870418804589ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-2812371870418804589ss-q-date">
<div class=3D"m_-2812371870418804589ss-datetime-box m_-2812371870418804589goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name=3D"entry.1705849412_month" disabled class=3D"m_-2812371870418804589ss-month-dropdown" id=3D"m_-2812371870418804589entry.1705849412_month">
<option value==3D"">
Month</option>
<option value=3D"1">
January</option>
 <option value=3D"2">
February</option>
 <option value=3D"3">
March</option>
 <option value=3D"4" selected>
April</option>
 <option value=3D"5">
May</option>
 <option value=3D"6">
June</option>
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July</option>
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August</option>
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September</option>
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October</option>
 <option value=3D"11">
November</option>
 <option value=3D"12">
December</option>
</select>
   <select name=3D"entry.1705849412_day" disabled class=3D"m_-2812371870418804589ss-day-dropdown" id=3D"m_-2812371870418804589entry.1705849412_day">
<option value=3D"">
Day</option>
<option value=3D"1">
1</option>
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2</option>
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3</option>
 <option value=3D"4">
4</option>
 <option value=3D"5" selected>
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>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_-2812371870418804589entry.1705849412_year">
<option value=3D"">
Year</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
 <option value=3D"1898">
1898</option>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
1901</option>
 <option value=3D"1902">
1902</option>
 <option value=3D"1903">
1903</option>
 <option value=3D"1904">
1904</option>
 <option value=3D"1905">
1905</option>
 <option value=3D"1906">
1906</option>
 <option value=3D"1907">
1907</option>
 <option value=3D"1908">
1908</option>
 <option value=3D"1909">
1909</option>
 <option value=3D"1910">
1910</option>
 <option value=3D"1911">
1911</option>
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1912</option>
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1913</option>
 <option value=3D"1914">
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>
 <option value=3D"1920">
1920</option>
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1921</option>
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1922</option>
 <option value=3D"1923">
1923</option>
 <option value==3D"1924">
1924</option>
 <option value=3D"1925">
1925</option>
 <option value==3D"1926">
1926</option>
 <option value=3D"1927">
1927</option>
 <option value==3D"1928">
1928</option>
 <option value=3D"1929">
1929</option>
 <option value==3D"1930">
1930</option>
 <option value=3D"1931">
1931</option>
 <option value==3D"1932">
1932</option>
 <option value=3D"1933">
1933</option>
 <option value==3D"1934">
1934</option>
 <option value=3D"1935">
1935</option>
 <option value==3D"1936">
1936</option>
 <option value=3D"1937">
1937</option>
 <option value==3D"1938">
1938</option>
 <option value=3D"1939">
1939</option>
 <option value==3D"1940">
1940</option>
 <option value=3D"1941">
1941</option>
 <option value==3D"1942">
1942</option>
 <option value=3D"1943">
1943</option>
 <option value==3D"1944">
1944</option>
 <option value=3D"1945">
1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
1948</option>
 <option value=3D"1949">
1949</option>
 <option value==3D"1950">
1950</option>
 <option value=3D"1951">
1951</option>
 <option value==3D"1952">
1952</option>
 <option value=3D"1953">
1953</option>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
 <option value=3D"1959">
1959</option>
 <option value==3D"1960">
1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
1976</option>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
 <option value==3D"1980">
1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
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1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
 <option value=3D"2011">
2011</option>
 <option value==3D"2012">
2012</option>
 <option value=3D"2013">
2013</option>
 <option value==3D"2014">
2014</option>
 <option value=3D"2015">
2015</option>
 <option value==3D"2016">
2016</option>
 <option value=3D"2017">
2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-item-required m_-2812371870418804589ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2812371870418804589ss-q-item-label" for=3D"m_-2812371870418804589entry_206244955">
<div class=3D"m_-2812371870418804589ss-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_-2812371870418804589itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2812371870418804589ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2812371870418804589ss-q-help m_-2812371870418804589ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-2812371870418804589ss-q-time">
<div class=3D"m_-2812371870418804589ss-datetime-box m_-2812371870418804589goog-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_-2812371870418804589entry.206244955_hour">
<option value=3D"">
Hr</option>
<option value=3D"01">
01</option>
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02</option>
 <option value=3D"03">
03</option>
 <option value=3D"04">
04</option>
 <option value=3D"05">
05</option>
 <option value=3D"06">
06</option>
 <option value=3D"07">
07</option>
 <option value=3D"08">
08</option>
 <option value=3D"09">
09</option>
 <option value=3D"10">
10</option>
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59</option>
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AM</option>
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PM</option>
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</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-item-required m_-2812371870418804589ss-select" style=3D"margin:12px 0">
<div class=3D"m_-2812371870418804589ss-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_-2812371870418804589ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_-2812371870418804589itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2812371870418804589ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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</div>
</label>
<select name=3D"entry.1747608258" disabled id=3D"m_-2812371870418804589entry_1747608258">
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</option>
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0</option>
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1</option>
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2</option>
 <option value=3D"3" disabled selected>
3</option>
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4</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2812371870418804589ss-q-item-label" for=3D"m_-2812371870418804589entry_1716090865">
<div class=3D"m_-2812371870418804589ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_-2812371870418804589ss-q-help m_-2812371870418804589ss-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_-2812371870418804589entry_1421689035">
<tbody>
<tr>
<td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1421689035_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1421689035_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-2812371870418804589ss-scalerow m_-2812371870418804589ss-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_-2812371870418804589aria-todo">
</div>
</td>
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</div>
</td>
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</div>
</td>
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<div class=3D"m_-2812371870418804589ss-scalerow-fieldcell">
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</div>
</td>
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<div class=3D"m_-2812371870418804589ss-scalerow-fieldcell">
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</div>
</td>
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<div class=3D"m_-2812371870418804589ss-scalerow-fieldcell">
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</div>
</td>
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<div class=3D"m_-2812371870418804589ss-scalerow-fieldcell">
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</div>
</td>
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<div class=3D"m_-2812371870418804589ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_-2812371870418804589group_1421689035_7" class=3D"m_-2812371870418804589ss-q-radio">
</div>
</td>
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<div class=3D"m_-2812371870418804589ss-scalerow-fieldcell">
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</div>
</td>
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<div class=3D"m_-2812371870418804589ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_-2812371870418804589group_1421689035_9" class=3D"m_-2812371870418804589ss-q-radio">
</div>
</td>
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<div class=3D"m_-2812371870418804589ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_-2812371870418804589group_1421689035_10" class=3D"m_-2812371870418804589ss-q-radio">
</div>
</td>
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<div class=3D"m_-2812371870418804589ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"10" id=3D"m_-2812371870418804589group_1421689035_11" class=3D"m_-2812371870418804589ss-q-radio">
</div>
</td>
<td class=3D"m_-2812371870418804589ss-scalerow m_-2812371870418804589ss-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_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
<div dir=3D"auto" class=3D"m_-2812371870418804589ss-item m_-2812371870418804589ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2812371870418804589ss-q-item-label" for=3D"m_-2812371870418804589entry_2064050596">
<div class=3D"m_-2812371870418804589ss-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_-2812371870418804589ss-q-help m_-2812371870418804589ss-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_-2812371870418804589entry_1244707512">
<tbody>
<tr>
<td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1244707512_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1244707512_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2812371870418804589ss-scalenumber" for=3D"m_-2812371870418804589group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-2812371870418804589ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-2812371870418804589ss-scalerow m_-2812371870418804589ss-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_-2812371870418804589aria-todo">
</div>
</td>
<td class=3D"m_-2812371870418804589ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
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Escala Dolor EVA M=C3=ADnimo</div>
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5</label>
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6</label>
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9</label>
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10</label>
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</label>
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Se acude a Home Care ubicado en calle Sanhueza #104, Pedro de Valdivia, Concepci=C3=B3n el d=C3=ADa viernes 5 de abril 2019 en compa=C3=B1=C3=ADa de EU Nicol=C3=A1s Rodr=C3=ADguez.Al momento de la visita se encuentran presentes la paciente Mar=C3=ADa Ang==C3=A9lica Romero Pino, su hijo (familiar responsable) Rodolfo Lindl Romero y la EU encargada del centro. La informaci=C3=B3n recopilada es recogida del relato de su hijo Rodrigo y los informes m=C3=A9dicos facilitados.=E2=80=A2	Datos de la paciente:=20Mar=C3=ADa Ang=C3=A9lica Romero Pino, 81 a=C3=B1os de edad, RUT 3.602.556-5, profesora de franc=C3=A9s de profesi=C3=B3n con estudios universitarios completos, actualmente viuda, religi=C3=B3n cat=C3=B3lica. Sin noci=C3=B3n ni conciencia de enfermedad, familiar responsable informa que prefieren no informarle en detalle respecto a diagn=C3=B3stico de probable c=C3=A1ncer renal (no tiene confirmaci=C3=B3n por biopsia).=E2=80=A2	N=C3=BAcleo familiar compuesto por hijos Rodolfo (52 a=C3=B1os, San Pedro de la Paz) y Rodrigo (51 a=C3=B1os, Santiago).Breve historia cl=C3=ADnica:Paciente con antecedentes de hipertensi=C3=B3n arterial, fibrilaci=C3=B3n auricular, usuaria de marcapaso bicameral, hipoacusia derecha, usuaria de aud=C3=ADfono derecho, inicia en enero 2019 con compromiso del estado general, dolor lumbar derecho y edema de extremidades inferiores. Inicia estudio con ecograf=C3=ADa doppler EEII (27/02/19): edema subcut=C3=A1neo inespec=C3=ADfico, sin signos de TVP. Posteriormente TAC TAP c/c (28/02/19): derrame pleural bilateral, pulmones sanos. Cardiomegalia. Quiste hep=C3=A1tico simple l=C3=B3bulo izquierdo. A nivel renal derecho masa s=C3=B3lido qu=C3=ADstica exof=C3=ADtica de 20x10x10 cm con infiltraci=C3=B3n hacia pared abdominal posterior. L=C3=ADquido libre en cavidad abdominal.=20Se hospitaliza en Cl=C3=ADnica Sanatorio Alem=C3=A1n desde el 01/03/19 hasta el 07/01/19 para eventual resoluci=C3=B3n quir=C3=BArgica, pero familia en conjunto con equipo m=C3=A9dico, dadas caracter=C3=ADsticas de la paciente, deciden manejo conservador e ingreso a GES Cuidados Paliativos (no se realiza biopsia de lesi=C3=B3n, por tanto el diagn=C3=B3stico de c=C3=A1ncer renal es s=C3=B3lo una hip=C3=B3tesis).Se decide su ingreso a centro Home Care donde actualmente reside el 11/03/19, donde es visitada por equipo asignado de Cuidados Paliativos. Durante dichas evaluaciones, se constata paciente en regular estado general, deca=C3==ADda, con =C3=A1nimo bajo, tendencia al sue=C3=B1o y a la hipotensi=C3=B3n, con dolor lumbar intenso EVA 7/10 y orina de mal olor. Inicialmente se indica tratamiento antibi=C3=B3tico endovenoso en el mismo centro. TAC AP c/c (27/03/19): extensa colecci=C3=B3n perirrenal derecha que desplaza al ri==C3=B1=C3=B3n hacia anterior, con compromiso del psoas, de 380 cc aprox, y que fistuliza a trav=C3=A9s de musculatura de pared lumbar posterior hacia subcut=C3=A1neo, con colecci=C3=B3n a ese nivel de 1,1 litros aprox. Ecocardiograma doppler color (28/03/19): disfunci=C3=B3n leve VI por hipokinesia global, dilataci=C3=B3n severa de AI, insuficiencia mitral severa, enfermedad valvular a=C3=B3rtica, insuficiencia tricusp=C3=ADdea severa, elevaci=C3=B3n severa de presi=C3=B3n venosa central, derrame peric=C3=A1rdico leve, derrame pleural bilateral, ascitis. Re ingresa a Cl=C3=ADnica Sanatorio Alem=C3=A1n el d=C3=ADa 29/03/19, ingresando a pabell=C3=B3n el mismo d=C3=ADa para aseo quir=C3=BArgico, con cultivo de secreci=C3=B3n del absceso positivo para E coli multisusceptible. Evoluciona sin incidentes, por lo que se da de alta el 02/04/19 con indicaci=C3=B3n de ciprofloxacino 500mg/12hrs x5 d=C3=ADas. No se consigna en epicrisis, pero seg=C3=BAn familiar requiri==C3=B3 transfusi=C3=B3n de 2U gl=C3=B3bulos rojos y 5U plaquetas.=20=C3=9Altimos ex=C3=A1menes durante la hospitalizaci=C3=B3n (02/04/19), destacan: Hb 7,9, plaquetas 49.000, leucocitos 4.200, sodio 132, potasio 3,2, cloro 95, calcio no corregido 8.0, f=C3=B3sforo 3,6, crea 0,6, VFG &gt;60. Alb=C3=BAmina 2,2 del 27/03/19Evaluaci=C3=B3n viernes 5 abril 2019Paciente en cama con colch=C3=B3n antiescaras, que requiere asistencia para movilizarse, sin ayudas t=C3=A9cnicas. Sin dolor durante la evaluaci=C3=B3n. Refiere constipaci=C3=B3n y =C3=A1nimo bajo. Apetito conservado, aliment=C3=A1ndose sin dificultad, sin s=C3=ADntomas urinarios ni de otros sistemas.</div>
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PA 140/64, FC 78, FR 17, saturando 95% con ox=C3=ADgeno ambiental, 36=C2=B0C axilarPalidez de piel y mucosas, sin adenopat=C3=ADas palpables, bien hidratada y perfundida, RI2T sin soplos audibles durante la evaluaci=C3=B3n, MP + con escasos cr=C3=A9pitos bibasales, abdomen con RHA conservados, indoloro, depresible, sin dolor a la maniobra de peloteo renal, edema sim=C3=A9trico de extremidades inferiores sin signos de trombosis venosa profunda. Ap=C3=B3sito en zona lumbar derecha, con piel sana, no eritematosa ni caliente, con dos soluciones de continuidad que corresponden a orificios de trayectos fistulosos.</div>
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=E2=80=A2	Tumor renal derecho, obs c==C3=A1ncer renal =E2=80=A2	Hipertensi=C3=B3n arterial  =E2=80=A2	Insuficiencia card=C3=ADaca de origen valvular =E2=80=A2	Fibrilaci=C3=B3n auricular en control de frecuencia, sin TACO =E2=80=A2	Bloqueo completo de rama derecha =E2=80=A2	Usuaria de marcapaso bicameral, instalado en marzo 2018 por bradicardia sintom=C3=A1tica  =E2=80=A2	Bicitopenia (anemia y trombocitopenia, con necesidad de transfusi=C3=B3n de hemoderivados en dos ocasiones) =E2==80=A2	Hipoalbuminemia =E2=80=A2	Anasarca (derrame pleural bilateral, derrame peric=C3=A1rdico leve,ascitis, edema extremidades inferiores) =E2=80=A2	Hiponatremia e hipokalemia leves =E2=80=A2	Hipoacusia bilateral, usuaria aud=C3=ADfono derecho =E2=80=A2	Dependencia moderada =E2=80=A2	Institucionalizada en centro privado</div>
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Plan de Tratamiento e Indicaciones<label for=3D"m_-2812371870418804589itemView.getDomIdToLabel()">
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Planes:=E2=80=A2	Completar tratamiento antibi=C3=B3tico indicado durante hospitalizaci=C3=B3n=E2=80=A2	Manejo del dolor=E2=80=A2	Optimizar uso de lactulosa para manejo de constipaci=C3=B3n=20=E2=80=A2	Suplementaci=C3=B3n con potasio oral seg=C3=BAn indicado al alta de su =C3=BAltima hospitalizaci=C3=B3n=E2=80=A2	En pr=C3=B3xima visita entregar=C3=A9 receta cheque para parches de buprenorfinaIndicaciones:1)	Reposo relativo, deambular con asistencia.=202)	R=C3=A9gimen com=C3=BAn, hidrataci=C3=B3n oral abundante3)	Cambio de posici=C3=B3n cada 3-4 hrs. Uso colch=C3=B3n antiescaras4)	Curaci=C3=B3n diaria de zona lumbar por enfermer=C3=ADa5)	Control con m=C3=A9dica y enfermero GES CP en 1 semana, d=C3=ADa a coordinar6)	Evaluaci=C3=B3n por nutricionista y psic=C3=B3loga=207)	Solicito kinesiterapia motora para rehabilitaci=C3=B3n post hospitalizaci=C3=B3n</div>
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Medicamentos Indicados</div>
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1)	Buprenorfina 35ug, =C2=BD parche cada 3,5 d=C3=ADas2)	Paracetamol 500mg/8hrs vo3)	Tramadol 10 gotas vo SOS=204)	Bisoprolol 1,25mg/d=C3=ADa vo=205)	Olmesart=C3=A1n 40mg/d=C3=ADa vo=206)	Levotiroxina 25ug/d=C3=ADa vo (al menos media hr antes del desayuno y 1 hrs antes del omeprazol)7)	Ciprofloxacino 500mg/12hrs vo hasta completar 5 d=C3=ADas (hoy d=C3=ADa 3/5)8)	Omeprazol 20mg/12hrs vo hasta terminar uso de antibi=C3=B3tico, luego suspender9)	Escitalopran 5mg/d=C3=ADa vo=2010)	Quetiapina 12,5mg/noche vo=2011)	Furosemida 40mg/d=C3=ADa vo=2012)	Vitamina C, 1 comp efervescente al d=C3=ADa vo=2013)	Centrum silver 1 comp/d=C3=ADa vo=2014)	Lactulosa jarabe, 10-30cc/6-8hrs, lo necesario para 2-3 deposiciones semiformadas al d=C3=ADa (se educa a EU del centro de residencia)15)	Slow K 1 comp/8hrs x3 d=C3=ADas, luego 1comp/12hrsx3 d=C3=ADas, luego 1 comp/d=C3=ADa hasta finalizar caja, vo </div>
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Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
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1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
1976</option>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
 <option value==3D"1980">
1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
 <option value=3D"2011">
2011</option>
 <option value==3D"2012">
2012</option>
 <option value=3D"2013">
2013</option>
 <option value==3D"2014">
2014</option>
 <option value=3D"2015">
2015</option>
 <option value==3D"2016">
2016</option>
 <option value=3D"2017">
2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
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<label class=3D"m_-2812371870418804589ss-q-item-label" for=3D"m_-2812371870418804589entry_74766472">
<div class=3D"m_-2812371870418804589ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_-2812371870418804589ss-q-help m_-2812371870418804589ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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</label>
<div class=3D"m_-2812371870418804589ss-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%">
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<br>
 <div class=3D"m_-2812371870418804589ss-form-question m_-2812371870418804589errorbox-good">
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<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2812371870418804589ss-q-item-label" for=3D"m_-2812371870418804589entry_1219705969">
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Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_-2812371870418804589ss-q-help m_-2812371870418804589ss-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_-2812371870418804589ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-2812371870418804589ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-2812371870418804589ss-choice-item-control m_-2812371870418804589goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"ENFERMERA" id=3D"m_-2812371870418804589group_503039759_1" class=3D"m_-2812371870418804589ss-q-checkbox">
</span>
<span class=3D"m_-2812371870418804589ss-choice-label">
ENFERMERA</span>
</label>
</li>
 <li class=3D"m_-2812371870418804589ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-2812371870418804589ss-choice-item-control m_-2812371870418804589goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_-2812371870418804589group_503039759_2" class=3D"m_-2812371870418804589ss-q-checkbox">
</span>
<span class=3D"m_-2812371870418804589ss-choice-label">
TENS</span>
</label>
</li>
 <li class=3D"m_-2812371870418804589ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-2812371870418804589ss-choice-item-control m_-2812371870418804589goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"NUTRICIONISTA" id=3D"m_-2812371870418804589group_503039759_3" class=3D"m_-2812371870418804589ss-q-checkbox">
</span>
<span class=3D"m_-2812371870418804589ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
 <li class=3D"m_-2812371870418804589ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-2812371870418804589ss-choice-item-control m_-2812371870418804589goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"KINESIOLOGO" id=3D"m_-2812371870418804589group_503039759_4" class=3D"m_-2812371870418804589ss-q-checkbox">
</span>
<span class=3D"m_-2812371870418804589ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
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<label>
<span class=3D"m_-2812371870418804589ss-choice-item-control m_-2812371870418804589goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"PSICOLOGO" id=3D"m_-2812371870418804589group_503039759_5" class=3D"m_-2812371870418804589ss-q-checkbox">
</span>
<span class=3D"m_-2812371870418804589ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2812371870418804589errorbox-good">
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<div class=3D"m_-2812371870418804589ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-2812371870418804589ss-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_-2812371870418804589ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
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</div>
<br>
</form>
</div>
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</tr>
</tbody>
</table>
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<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242;font-size:13px" target=3D"_blank">
Create your own Google Form</a>
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</tbody>
</table>
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<br>
 <table style=3D"border-top:1px solid #d3d4de">
	<tr>
      <td style=3D"width:55px;padding-top:18px">
<a href=3D"http://www.avg.com/email-signature?utm_medium=3Demail&amp;utm_source=3Dlink&amp;utm_campaign=3Dsig-email&amp;utm_content=3Dwebmail" target=3D"_blank">
<img src=3D"https://ipmcdn.avast.com/images/icons/icon-envelope-tick-green-avg-v1.png" alt==3D"" width=3D"46" height=3D"29" style=3D"width: 46px; height: 29px;">
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</td>
		<td style=3D"width:470px;padding-top:17px;color:#41424e;font-size:13px;font-family:Arial,Helvetica,sans-serif;line-height:18px">
Libre de virus. <a href=3D"http://www.avg.com/email-signature?utm_medium=3Demail&amp;utm_source=3Dlink&amp;utm_campaign=3Dsig-email&amp;utm_content=3Dwebmail" target=3D"_blank" style=3D"color:#4453ea">
www.avg.com</a>
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<a href=3D"#DAB4FAD8-2DD7-40BB-A1B8-4E2AA1F9FDF2" width=3D"1" height=3D"1">
</a>
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--000000000000721ba00585d22255--