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buen dia, envio copia de planilla de visita de la paciente gladys silva DX CA de vejiga realizada el dia 12/4/2019.</div>
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ATT: abdul sarria</div>
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medico</div>
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rut 26743483-2</div>
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<b>
De:</b>
 Formularios de Google &lt;forms-receipts-noreply@google.com&gt;<br>
<b>
Enviado:</b>
 s=E1bado, 13 de abril de 2019 11:58 a.m.<br>
<b>
Para:</b>
 abdul2508@hotmail.com<br>
<b>
Asunto:</b>
 Registro de Atenci=F3n Domiciliaria Oncovida</font>
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&nbsp;</div>
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<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%" role=3D"presentation" style=3D"background-color:rgb(38,4,154)">
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<img alt=3D"Formularios de Google" height==3D"26px" width=3D"143px" style=3D"display:inline-block; margin:0; vertical-align:middle" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
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</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" width=3D"100%" role=3D"presentation" style=3D"background-color:#fff">
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<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">
Registro de Atenci=F3n Domiciliaria Oncovida</a>
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<tr height=3D"12px">
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<div style=3D"font-size:13px; line-height:18px; color:#424242">
Esto es lo que nos has enviado:</div>
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<td>
<div class=3D"ss-form-container" style=3D"">
<div class=3D"ss-form-heading" style=3D"">
<h1 class=3D"ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=F3n Domiciliaria Oncovida</h1>
<div class=3D"ss-form-desc ss-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=F3n indique su correo electr=F3nico.</div>
</div>
<div class=3D"ss-form" style=3D"">
<form action=3D"" method=3D"GET" id=3D"ss-form" style=3D"">
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"emailAddress" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Direcci=F3n de correo electr=F3nico <label for=3D"emailAddress" aria-label==3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"ss-q-text ss-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%">
abdul2508@hotmail.com</div>
</div>
</div>
</div>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style==3D"margin:12px 0; max-width:100%">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-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"ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ">
</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-page-title" style=3D"padding:0.4em; background-color:#eee">
Identificaci=F3n del Prestador</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap; word-wrap:break-word">
Aqu=ED debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_579114469" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Primer Nombre y Apellido Paterno <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-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%">
abdul sarria</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1276273985" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
RUT <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
RUT con Gui=F3n y D=EDgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"ss-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%">
26743483-2</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-select" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_133691676" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Tipo <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
Si asisten m=E1s de 1 prestador simult=E1neamente, cada uno debe hacer un registro independiente</div>
</label>
<select name=3D"entry.133691676" disabled=3D"" id=3D"entry_133691676" aria-label=3D"Tipo Si asisten m=E1s de 1 prestador simult=E1neamente, cada uno debe hacer un registro independiente " style=3D"">
<option value=3D"" style=3D"">
</option>
 <option value=3D"MEDICO" disabled=3D"" selected=3D"" style=3D"">
MEDICO</option>
<option value=3D"ENFERMERA/O" disabled=3D"" style=3D"">
ENFERMERA/O</option>
 <option value=3D"TENS" disabled=3D"" style=3D"">
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled=3D"" style=3D"">
KINESIOLOGA/O</option>
<option value=3D"PSICOLOGO" disabled=3D"" style=3D"">
PSICOLOGO</option>
 <option value=3D"NUTRICIONISTA" disabled=3D"" style=3D"">
NUTRICIONISTA</option>
</select>
 </div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style==3D"margin:12px 0; max-width:100%">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-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"ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA">
</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-page-title" style=3D"padding:0.4em; background-color:#eee">
Identificaci=F3n del Paciente</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap; word-wrap:break-word">
En esta secci=F3n debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-section-header" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-section-title" style=3D"background-color:#eee; padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"ss-section-description ss-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"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_823811303" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Ingrese el Rut del Paciente <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
RUT con Gui=F3n y D=EDgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"ss-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%">
3490302-6</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1959365839" style=3D"">
<div class=3D"ss-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"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-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%">
gladys silva</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-select" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_545002227" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Previsi=F3n <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<select name=3D"entry.545002227" disabled=3D"" id=3D"entry_545002227" aria-label=3D"Previsi=F3n  " style=3D"">
<option value=3D"" style=3D"">
</option>
 <option value=3D"BANMEDICA" disabled=3D"" style=3D"">
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled=3D"" style=3D"">
CAPREDENA</option>
 <option value=3D"COLMENA" disabled=3D"" style=3D"">
COLMENA</option>
 <option value=3D"CONSALUD" disabled=3D"" style=3D"">
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled=3D"" style=3D"">
CRUZ BLANCA</option>
<option value=3D"DIPRECA" disabled=3D"" style=3D"">
DIPRECA</option>
 <option value=3D"FONASA" disabled=3D"" style=3D"">
FONASA</option>
 <option value=3D"FUNDACION" disabled=3D"" style=3D"">
FUNDACION</option>
<option value=3D"ISAPRES DEL COBRE" disabled=3D"" selected=3D"" style=3D"">
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled=3D"" style=3D"">
NUEVA MASVIDA</option>
<option value=3D"VIDATRES" disabled=3D"" style=3D"">
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled=3D"" style=3D"">
PARTICULAR</option>
</select>
 </div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1900161356" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Ciudad <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-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%">
antofagasta</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1298871758" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Comuna <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-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%">
antofagasta</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style==3D"margin:12px 0; max-width:100%">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-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"ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ">
</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-page-title" style=3D"padding:0.4em; background-color:#eee">
Registro de la Atenci=F3n Domiciliaria</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap; word-wrap:break-word">
En esta secci=F3n debe ingresar los datos de la atenci=F3n domiciliaria</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-radio" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_2073233714" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Tipo de Atenci=F3n <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<ul class=3D"ss-choices" role=3D"radiogroup" aria-label=3D"Tipo de Atenci==F3n  " style=3D"list-style:none; padding:0; margin:.5em 0 0">
<li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled=3D"" checked=3D"" value=3D"Domicilio" id=3D"group_1222378237_1" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"Domicilio" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
Domicilio</span>
 </label>
</li>
<li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled=3D"" value=3D"Ambulatorio" id=3D"group_1222378237_2" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"Ambulatorio" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
Ambulatorio</span>
 </label>
</li>
</ul>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-date" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1705849412" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Fecha de la Atenci=F3n <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-date" role=3D"group" aria-label=3D"Fecha de la Atenci=F3n  " style=3D"">
<div class=3D"ss-datetime-box goog-inline-block" role=3D"group" 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=3D"" class=3D"ss-day-dropdown" id=3D"entry.1705849412_day" aria-label=3D"D=EDa del mes" style=3D"">
<option value=3D"" style=3D"">
D=EDa</option>
 <option value=3D"1" style=3D"">
1</option>
 <option value=3D"2" style=3D"">
2</option>
<option value=3D"3" style=3D"">
3</option>
 <option value=3D"4" style=3D"">
4</option>
 <option value=3D"5" style=3D"">
5</option>
 <option value=3D"6" style=3D"">
6</option>
 <option value=3D"7" style=3D"">
7</option>
<option value=3D"8" style=3D"">
8</option>
 <option value=3D"9" style=3D"">
9</option>
 <option value=3D"10" style=3D"">
10</option>
 <option value=3D"11" style=3D"">
11</option>
 <option value=3D"12" selected=3D"" style=3D"">
12</option>
 <option value=3D"13" style=3D"">
13</option>
 <option value=3D"14" style=3D"">
14</option>
 <option value=3D"15" style=3D"">
15</option>
 <option value=3D"16" style=3D"">
16</option>
<option value=3D"17" style=3D"">
17</option>
 <option value=3D"18" style=3D"">
18</option>
 <option value=3D"19" style=3D"">
19</option>
 <option value=3D"20" style=3D"">
20</option>
 <option value=3D"21" style=3D"">
21</option>
 <option value=3D"22" style=3D"">
22</option>
 <option value=3D"23" style=3D"">
23</option>
<option value=3D"24" style=3D"">
24</option>
 <option value=3D"25" style=3D"">
25</option>
 <option value=3D"26" style=3D"">
26</option>
 <option value=3D"27" style=3D"">
27</option>
 <option value=3D"28" style=3D"">
28</option>
 <option value=3D"29" style=3D"">
29</option>
 <option value=3D"30" style=3D"">
30</option>
<option value=3D"31" style=3D"">
31</option>
</select>
 <select name=3D"entry.1705849412_month" disabled=3D"" class=3D"ss-month-dropdown" id=3D"entry.1705849412_month" aria-label=3D"Mes" style=3D"">
<option value=3D"" style=3D"">
Mes</option>
 <option value=3D"1" style=3D"">
enero</option>
 <option value=3D"2" style=3D"">
febrero</option>
 <option value=3D"3" style=3D"">
marzo</option>
 <option value=3D"4" selected=3D"" style=3D"">
abril</option>
 <option value=3D"5" style=3D"">
mayo</option>
 <option value==3D"6" style=3D"">
junio</option>
 <option value=3D"7" style=3D"">
julio</option>
 <option value==3D"8" style=3D"">
agosto</option>
 <option value=3D"9" style=3D"">
septiembre</option>
 <option value=3D"10" style=3D"">
octubre</option>
 <option value=3D"11" style=3D"">
noviembre</option>
 <option value=3D"12" style=3D"">
diciembre</option>
</select>
 <select name=3D"entry.1705849412_year" disabled=3D"" id=3D"entry.1705849412_year" aria-label=3D"A=F1o" style=3D"">
<option value=3D"" style=3D"">
A=F1o</option>
 <option value=3D"1896" style=3D"">
1896</option>
 <option value=3D"1897" style=3D"">
1897</option>
 <option value=3D"1898" style=3D"">
1898</option>
 <option value=3D"1899" style=3D"">
1899</option>
 <option value=3D"1900" style=3D"">
1900</option>
 <option value=3D"1901" style=3D"">
1901</option>
 <option value=3D"1902" style=3D"">
1902</option>
 <option value=3D"1903" style=3D"">
1903</option>
 <option value=3D"1904" style=3D"">
1904</option>
 <option value=3D"1905" style=3D"">
1905</option>
 <option value=3D"1906" style=3D"">
1906</option>
 <option value=3D"1907" style=3D"">
1907</option>
 <option value=3D"1908" style=3D"">
1908</option>
 <option value=3D"1909" style=3D"">
1909</option>
 <option value=3D"1910" style=3D"">
1910</option>
 <option value=3D"1911" style=3D"">
1911</option>
 <option value=3D"1912" style=3D"">
1912</option>
 <option value=3D"1913" style=3D"">
1913</option>
 <option value=3D"1914" style=3D"">
1914</option>
 <option value=3D"1915" style=3D"">
1915</option>
 <option value=3D"1916" style=3D"">
1916</option>
 <option value=3D"1917" style=3D"">
1917</option>
 <option value=3D"1918" style=3D"">
1918</option>
 <option value=3D"1919" style=3D"">
1919</option>
 <option value=3D"1920" style=3D"">
1920</option>
 <option value=3D"1921" style=3D"">
1921</option>
 <option value=3D"1922" style=3D"">
1922</option>
 <option value=3D"1923" style=3D"">
1923</option>
 <option value=3D"1924" style=3D"">
1924</option>
 <option value=3D"1925" style=3D"">
1925</option>
 <option value=3D"1926" style=3D"">
1926</option>
 <option value=3D"1927" style=3D"">
1927</option>
 <option value=3D"1928" style=3D"">
1928</option>
 <option value=3D"1929" style=3D"">
1929</option>
 <option value=3D"1930" style=3D"">
1930</option>
 <option value=3D"1931" style=3D"">
1931</option>
 <option value=3D"1932" style=3D"">
1932</option>
 <option value=3D"1933" style=3D"">
1933</option>
 <option value=3D"1934" style=3D"">
1934</option>
 <option value=3D"1935" style=3D"">
1935</option>
 <option value=3D"1936" style=3D"">
1936</option>
 <option value=3D"1937" style=3D"">
1937</option>
 <option value=3D"1938" style=3D"">
1938</option>
 <option value=3D"1939" style=3D"">
1939</option>
 <option value=3D"1940" style=3D"">
1940</option>
 <option value=3D"1941" style=3D"">
1941</option>
 <option value=3D"1942" style=3D"">
1942</option>
 <option value=3D"1943" style=3D"">
1943</option>
 <option value=3D"1944" style=3D"">
1944</option>
 <option value=3D"1945" style=3D"">
1945</option>
 <option value=3D"1946" style=3D"">
1946</option>
 <option value=3D"1947" style=3D"">
1947</option>
 <option value=3D"1948" style=3D"">
1948</option>
 <option value=3D"1949" style=3D"">
1949</option>
 <option value=3D"1950" style=3D"">
1950</option>
 <option value=3D"1951" style=3D"">
1951</option>
 <option value=3D"1952" style=3D"">
1952</option>
 <option value=3D"1953" style=3D"">
1953</option>
 <option value=3D"1954" style=3D"">
1954</option>
 <option value=3D"1955" style=3D"">
1955</option>
 <option value=3D"1956" style=3D"">
1956</option>
 <option value=3D"1957" style=3D"">
1957</option>
 <option value=3D"1958" style=3D"">
1958</option>
 <option value=3D"1959" style=3D"">
1959</option>
 <option value=3D"1960" style=3D"">
1960</option>
 <option value=3D"1961" style=3D"">
1961</option>
 <option value=3D"1962" style=3D"">
1962</option>
 <option value=3D"1963" style=3D"">
1963</option>
 <option value=3D"1964" style=3D"">
1964</option>
 <option value=3D"1965" style=3D"">
1965</option>
 <option value=3D"1966" style=3D"">
1966</option>
 <option value=3D"1967" style=3D"">
1967</option>
 <option value=3D"1968" style=3D"">
1968</option>
 <option value=3D"1969" style=3D"">
1969</option>
 <option value=3D"1970" style=3D"">
1970</option>
 <option value=3D"1971" style=3D"">
1971</option>
 <option value=3D"1972" style=3D"">
1972</option>
 <option value=3D"1973" style=3D"">
1973</option>
 <option value=3D"1974" style=3D"">
1974</option>
 <option value=3D"1975" style=3D"">
1975</option>
 <option value=3D"1976" style=3D"">
1976</option>
 <option value=3D"1977" style=3D"">
1977</option>
 <option value=3D"1978" style=3D"">
1978</option>
 <option value=3D"1979" style=3D"">
1979</option>
 <option value=3D"1980" style=3D"">
1980</option>
 <option value=3D"1981" style=3D"">
1981</option>
 <option value=3D"1982" style=3D"">
1982</option>
 <option value=3D"1983" style=3D"">
1983</option>
 <option value=3D"1984" style=3D"">
1984</option>
 <option value=3D"1985" style=3D"">
1985</option>
 <option value=3D"1986" style=3D"">
1986</option>
 <option value=3D"1987" style=3D"">
1987</option>
 <option value=3D"1988" style=3D"">
1988</option>
 <option value=3D"1989" style=3D"">
1989</option>
 <option value=3D"1990" style=3D"">
1990</option>
 <option value=3D"1991" style=3D"">
1991</option>
 <option value=3D"1992" style=3D"">
1992</option>
 <option value=3D"1993" style=3D"">
1993</option>
 <option value=3D"1994" style=3D"">
1994</option>
 <option value=3D"1995" style=3D"">
1995</option>
 <option value=3D"1996" style=3D"">
1996</option>
 <option value=3D"1997" style=3D"">
1997</option>
 <option value=3D"1998" style=3D"">
1998</option>
 <option value=3D"1999" style=3D"">
1999</option>
 <option value=3D"2000" style=3D"">
2000</option>
 <option value=3D"2001" style=3D"">
2001</option>
 <option value=3D"2002" style=3D"">
2002</option>
 <option value=3D"2003" style=3D"">
2003</option>
 <option value=3D"2004" style=3D"">
2004</option>
 <option value=3D"2005" style=3D"">
2005</option>
 <option value=3D"2006" style=3D"">
2006</option>
 <option value=3D"2007" style=3D"">
2007</option>
 <option value=3D"2008" style=3D"">
2008</option>
 <option value=3D"2009" style=3D"">
2009</option>
 <option value=3D"2010" style=3D"">
2010</option>
 <option value=3D"2011" style=3D"">
2011</option>
 <option value=3D"2012" style=3D"">
2012</option>
 <option value=3D"2013" style=3D"">
2013</option>
 <option value=3D"2014" style=3D"">
2014</option>
 <option value=3D"2015" style=3D"">
2015</option>
 <option value=3D"2016" style=3D"">
2016</option>
 <option value=3D"2017" style=3D"">
2017</option>
 <option value=3D"2018" style=3D"">
2018</option>
 <option value=3D"2019" selected=3D"" style=3D"">
2019</option>
 <option value=3D"2020" style=3D"">
2020</option>
 <option value=3D"2021" style=3D"">
2021</option>
 <option value=3D"2022" style=3D"">
2022</option>
 <option value=3D"2023" style=3D"">
2023</option>
 <option value=3D"2024" style=3D"">
2024</option>
 <option value=3D"2025" style=3D"">
2025</option>
 <option value=3D"2026" style=3D"">
2026</option>
 <option value=3D"2027" style=3D"">
2027</option>
 <option value=3D"2028" style=3D"">
2028</option>
 <option value=3D"2029" style=3D"">
2029</option>
 <option value=3D"2030" style=3D"">
2030</option>
 <option value=3D"2031" style=3D"">
2031</option>
 <option value=3D"2032" style=3D"">
2032</option>
 <option value=3D"2033" style=3D"">
2033</option>
 <option value=3D"2034" style=3D"">
2034</option>
 <option value=3D"2035" style=3D"">
2035</option>
 <option value=3D"2036" style=3D"">
2036</option>
 <option value=3D"2037" style=3D"">
2037</option>
 <option value=3D"2038" style=3D"">
2038</option>
 <option value=3D"2039" style=3D"">
2039</option>
 <option value=3D"2040" style=3D"">
2040</option>
 <option value=3D"2041" style=3D"">
2041</option>
 <option value=3D"2042" style=3D"">
2042</option>
 <option value=3D"2043" style=3D"">
2043</option>
 <option value=3D"2044" style=3D"">
2044</option>
 <option value=3D"2045" style=3D"">
2045</option>
 <option value=3D"2046" style=3D"">
2046</option>
 <option value=3D"2047" style=3D"">
2047</option>
 <option value=3D"2048" style=3D"">
2048</option>
 <option value=3D"2049" style=3D"">
2049</option>
 <option value=3D"2050" style=3D"">
2050</option>
 <option value=3D"2051" style=3D"">
2051</option>
 <option value=3D"2052" style=3D"">
2052</option>
 <option value=3D"2053" style=3D"">
2053</option>
 <option value=3D"2054" style=3D"">
2054</option>
 <option value=3D"2055" style=3D"">
2055</option>
 <option value=3D"2056" style=3D"">
2056</option>
 <option value=3D"2057" style=3D"">
2057</option>
 <option value=3D"2058" style=3D"">
2058</option>
 <option value=3D"2059" style=3D"">
2059</option>
 <option value=3D"2060" style=3D"">
2060</option>
 <option value=3D"2061" style=3D"">
2061</option>
 <option value=3D"2062" style=3D"">
2062</option>
 <option value=3D"2063" style=3D"">
2063</option>
 <option value=3D"2064" style=3D"">
2064</option>
 <option value=3D"2065" style=3D"">
2065</option>
 <option value=3D"2066" style=3D"">
2066</option>
 <option value=3D"2067" style=3D"">
2067</option>
 <option value=3D"2068" style=3D"">
2068</option>
 <option value=3D"2069" style=3D"">
2069</option>
</select>
 </div>
</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-time" style=3D"margin:12px 0; font:inherit">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_206244955" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Hora de la Atenci=F3n <label for=3D"itemView.getDomIdToLabel()" aria-label==3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-time" style=3D"">
<div class=3D"ss-datetime-box goog-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=3D"" id=3D"entry.206244955_hour" aria-label=3D"Hora" style=3D"">
<option value=3D"" style=3D"">
h</option>
 <option value=3D"00" style=3D"">
00</option>
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Escala Dolor EVA Actual </div>
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Escala Dolor EVA M=E1ximo </div>
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3</label>
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4</label>
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5</label>
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6</label>
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7</label>
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8</label>
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9</label>
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10</label>
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<div aria-hidden=3D"true" class=3D"aria-todo" style=3D"">
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<td class=3D"ss-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=EDnimo </div>
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5</label>
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7</label>
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8</label>
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paciente de 84 a=F1os de edad con antecedentes de m=FAltiples patol=F3gicas metab=F3licas en tto medico controladas, asociado a dx de CA de vejiga que tto de radioterapia y extracci=F3n de tumor hace mas de 6 meses, actualmente en cuidado paliativo y manejo del dolor con paracetamol SOS, con funcionalidad reducida, necesita ayuda para desplazarse y realizar actividades b=E1sicas, a cuidado del esposo principalmente, la encuentro en buenas condiciones generales, en cama, orientada en sus tres esferas mentales, somnolienta, colaboradora, familiares refieren s=EDntomas de urgencia urinaria que incluso interfieren con el sue=F1o, y dolor abdominal ocasional que cede con el uso del paracetamol, ademas refieren verla somnolienta cada vez mas, niegan fiebre, niegan intolerancia a la v=EDa oral, niega dolor tor=E1cico, paciente no refiere dolor en el momento ni molestia. presentan ectomografia abdominal que reporta gran hidronefrosis bilateral solicitado por medico en consultas anteriores, llama la atencion que por patologias de base cronicas y ca no tiene en sus ultimos 3 meses control metabolico en sus examenes.</div>
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Examen F=EDsico <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
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paciente luce en aparente buenas condiciones generales, somnolienta, sin signos de dificultad respiratoria, svt: ta 129/70 fc 75 fr 18 t36 sto 98, mucosas hidratadas, conjuntivas rosadas, escleras anictericas, cavidad oral sin alteraci=F3n, cuello m=F3vil no doloroso, ni adenopatias, ruidos card=EDacos r=EDtmicos y regulares no soplos, campos pulmonares bien ventilados sin sobre agregados abdomen blando depresible con dolor difuso a la palpaci=F3n profunda principalmente en mesogastrio, hipogastrio, y zona pelvica, a nivel abdominal se evidencia onda ascitica sin ascitis considerable, GU sin uso de pa=F1al no se palpa globo vesical, extremidades sim=E9tricas m=F3viles, sin edemas no dolorosas, sin escaras ni ulceras, glasgow 15/15.</div>
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ca vejiga en cuidado paliativo </div>
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</label>
<div class=3D"ss-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 m=FAltiples patolog=EDas de base ( hta-dmt2-hipotiroidismo) con c=E1ncer asociado en cuidado paliativo, funcionalidad reducida, por edad y condiciones alto riesgo de complicaciones metab=F3licas, luce en aparentes buenas, con urgencia urinaria que interfiere con el sue=F1o, origen de la somnolencia?, con considerable hidronefrosis bilateral reportada en ectomografia abdominal, con presencia de masa a nivel ureteral que obstruye, con dolor controlado con uso de paracetamol SOS se recomienda 1gr dado el caso, se adiciona trazadona 50mg cada noche. se solicitan ex=E1menes de control: perfil hepatico, glicemia, uremia, creatinia, perfil lip=EDdico, sodio, potasio, cloro, hemograma, protrombinemia, ttpa ttpk, orina completa, pcr cuantitativa, urocultivo, y electrocardiograma, paraclinicos a evaluar control metab=F3lico de la paciente. se educa sobre el manejo del dolor, cuidados personales, buena higuiene, medidas preventivas de escaras, se recomienda la presencia de cuidadora o paramedico para complementar cuidado de la paciente ya que principalmente se encuentra a cargo del esposo, se dan signos de alarma para consultar por urgencias.</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1648939075" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Medicamentos Indicados </div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-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%">
paracetamol 500mg, 1gr SOS. trazadona ta 50mg una cada noche. </div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-date" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_2063615873" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Fecha aproximada del Pr=F3ximo Control con usted </div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-date" role=3D"group" aria-label=3D"Fecha aproximada del Pr=F3ximo Control con usted  " style=3D"">
<div class=3D"ss-datetime-box goog-inline-block" role=3D"group" style=3D"border:1px solid #dcdcdc; margin-right:2em; min-height:32px; padding-left:3px; vertical-align:middle; margin:4px 3px; display:inline-block">
<select name=3D"entry.2063615873_day" disabled=3D"" class=3D"ss-day-dropdown" id=3D"entry.2063615873_day" aria-label=3D"D=EDa del mes" style=3D"">
<option value=3D"" style=3D"">
D=EDa</option>
 <option value=3D"1" style=3D"">
1</option>
 <option value=3D"2" style=3D"">
2</option>
<option value=3D"3" style=3D"">
3</option>
 <option value=3D"4" style=3D"">
4</option>
 <option value=3D"5" style=3D"">
5</option>
 <option value=3D"6" style=3D"">
6</option>
 <option value=3D"7" style=3D"">
7</option>
<option value=3D"8" style=3D"">
8</option>
 <option value=3D"9" style=3D"">
9</option>
 <option value=3D"10" style=3D"">
10</option>
 <option value=3D"11" style=3D"">
11</option>
 <option value=3D"12" style=3D"">
12</option>
 <option value=3D"13" style=3D"">
13</option>
 <option value=3D"14" style=3D"">
14</option>
<option value=3D"15" style=3D"">
15</option>
 <option value=3D"16" selected==3D"" style=3D"">
16</option>
 <option value=3D"17" style=3D"">
17</option>
 <option value=3D"18" style=3D"">
18</option>
<option value=3D"19" style=3D"">
19</option>
 <option value=3D"20" style=3D"">
20</option>
 <option value=3D"21" style=3D"">
21</option>
 <option value=3D"22" style=3D"">
22</option>
 <option value=3D"23" style=3D"">
23</option>
 <option value=3D"24" style=3D"">
24</option>
 <option value=3D"25" style=3D"">
25</option>
<option value=3D"26" style=3D"">
26</option>
 <option value=3D"27" style=3D"">
27</option>
 <option value=3D"28" style=3D"">
28</option>
 <option value=3D"29" style=3D"">
29</option>
 <option value=3D"30" style=3D"">
30</option>
 <option value=3D"31" style=3D"">
31</option>
</select>
 <select name=3D"entry.2063615873_month" disabled=3D"" class=3D"ss-month-dropdown" id=3D"entry.2063615873_month" aria-label=3D"Mes" style=3D"">
<option value=3D"" style=3D"">
Mes</option>
 <option value=3D"1" style=3D"">
enero</option>
 <option value=3D"2" style=3D"">
febrero</option>
 <option value=3D"3" style=3D"">
marzo</option>
 <option value=3D"4" selected=3D"" style=3D"">
abril</option>
 <option value=3D"5" style=3D"">
mayo</option>
 <option value==3D"6" style=3D"">
junio</option>
 <option value=3D"7" style=3D"">
julio</option>
 <option value==3D"8" style=3D"">
agosto</option>
 <option value=3D"9" style=3D"">
septiembre</option>
 <option value=3D"10" style=3D"">
octubre</option>
 <option value=3D"11" style=3D"">
noviembre</option>
 <option value=3D"12" style=3D"">
diciembre</option>
</select>
 <select name=3D"entry.2063615873_year" disabled=3D"" id=3D"entry.2063615873_year" aria-label=3D"A=F1o" style=3D"">
<option value=3D"" style=3D"">
A=F1o</option>
 <option value=3D"1896" style=3D"">
1896</option>
 <option value=3D"1897" style=3D"">
1897</option>
 <option value=3D"1898" style=3D"">
1898</option>
 <option value=3D"1899" style=3D"">
1899</option>
 <option value=3D"1900" style=3D"">
1900</option>
 <option value=3D"1901" style=3D"">
1901</option>
 <option value=3D"1902" style=3D"">
1902</option>
 <option value=3D"1903" style=3D"">
1903</option>
 <option value=3D"1904" style=3D"">
1904</option>
 <option value=3D"1905" style=3D"">
1905</option>
 <option value=3D"1906" style=3D"">
1906</option>
 <option value=3D"1907" style=3D"">
1907</option>
 <option value=3D"1908" style=3D"">
1908</option>
 <option value=3D"1909" style=3D"">
1909</option>
 <option value=3D"1910" style=3D"">
1910</option>
 <option value=3D"1911" style=3D"">
1911</option>
 <option value=3D"1912" style=3D"">
1912</option>
 <option value=3D"1913" style=3D"">
1913</option>
 <option value=3D"1914" style=3D"">
1914</option>
 <option value=3D"1915" style=3D"">
1915</option>
 <option value=3D"1916" style=3D"">
1916</option>
 <option value=3D"1917" style=3D"">
1917</option>
 <option value=3D"1918" style=3D"">
1918</option>
 <option value=3D"1919" style=3D"">
1919</option>
 <option value=3D"1920" style=3D"">
1920</option>
 <option value=3D"1921" style=3D"">
1921</option>
 <option value=3D"1922" style=3D"">
1922</option>
 <option value=3D"1923" style=3D"">
1923</option>
 <option value=3D"1924" style=3D"">
1924</option>
 <option value=3D"1925" style=3D"">
1925</option>
 <option value=3D"1926" style=3D"">
1926</option>
 <option value=3D"1927" style=3D"">
1927</option>
 <option value=3D"1928" style=3D"">
1928</option>
 <option value=3D"1929" style=3D"">
1929</option>
 <option value=3D"1930" style=3D"">
1930</option>
 <option value=3D"1931" style=3D"">
1931</option>
 <option value=3D"1932" style=3D"">
1932</option>
 <option value=3D"1933" style=3D"">
1933</option>
 <option value=3D"1934" style=3D"">
1934</option>
 <option value=3D"1935" style=3D"">
1935</option>
 <option value=3D"1936" style=3D"">
1936</option>
 <option value=3D"1937" style=3D"">
1937</option>
 <option value=3D"1938" style=3D"">
1938</option>
 <option value=3D"1939" style=3D"">
1939</option>
 <option value=3D"1940" style=3D"">
1940</option>
 <option value=3D"1941" style=3D"">
1941</option>
 <option value=3D"1942" style=3D"">
1942</option>
 <option value=3D"1943" style=3D"">
1943</option>
 <option value=3D"1944" style=3D"">
1944</option>
 <option value=3D"1945" style=3D"">
1945</option>
 <option value=3D"1946" style=3D"">
1946</option>
 <option value=3D"1947" style=3D"">
1947</option>
 <option value=3D"1948" style=3D"">
1948</option>
 <option value=3D"1949" style=3D"">
1949</option>
 <option value=3D"1950" style=3D"">
1950</option>
 <option value=3D"1951" style=3D"">
1951</option>
 <option value=3D"1952" style=3D"">
1952</option>
 <option value=3D"1953" style=3D"">
1953</option>
 <option value=3D"1954" style=3D"">
1954</option>
 <option value=3D"1955" style=3D"">
1955</option>
 <option value=3D"1956" style=3D"">
1956</option>
 <option value=3D"1957" style=3D"">
1957</option>
 <option value=3D"1958" style=3D"">
1958</option>
 <option value=3D"1959" style=3D"">
1959</option>
 <option value=3D"1960" style=3D"">
1960</option>
 <option value=3D"1961" style=3D"">
1961</option>
 <option value=3D"1962" style=3D"">
1962</option>
 <option value=3D"1963" style=3D"">
1963</option>
 <option value=3D"1964" style=3D"">
1964</option>
 <option value=3D"1965" style=3D"">
1965</option>
 <option value=3D"1966" style=3D"">
1966</option>
 <option value=3D"1967" style=3D"">
1967</option>
 <option value=3D"1968" style=3D"">
1968</option>
 <option value=3D"1969" style=3D"">
1969</option>
 <option value=3D"1970" style=3D"">
1970</option>
 <option value=3D"1971" style=3D"">
1971</option>
 <option value=3D"1972" style=3D"">
1972</option>
 <option value=3D"1973" style=3D"">
1973</option>
 <option value=3D"1974" style=3D"">
1974</option>
 <option value=3D"1975" style=3D"">
1975</option>
 <option value=3D"1976" style=3D"">
1976</option>
 <option value=3D"1977" style=3D"">
1977</option>
 <option value=3D"1978" style=3D"">
1978</option>
 <option value=3D"1979" style=3D"">
1979</option>
 <option value=3D"1980" style=3D"">
1980</option>
 <option value=3D"1981" style=3D"">
1981</option>
 <option value=3D"1982" style=3D"">
1982</option>
 <option value=3D"1983" style=3D"">
1983</option>
 <option value=3D"1984" style=3D"">
1984</option>
 <option value=3D"1985" style=3D"">
1985</option>
 <option value=3D"1986" style=3D"">
1986</option>
 <option value=3D"1987" style=3D"">
1987</option>
 <option value=3D"1988" style=3D"">
1988</option>
 <option value=3D"1989" style=3D"">
1989</option>
 <option value=3D"1990" style=3D"">
1990</option>
 <option value=3D"1991" style=3D"">
1991</option>
 <option value=3D"1992" style=3D"">
1992</option>
 <option value=3D"1993" style=3D"">
1993</option>
 <option value=3D"1994" style=3D"">
1994</option>
 <option value=3D"1995" style=3D"">
1995</option>
 <option value=3D"1996" style=3D"">
1996</option>
 <option value=3D"1997" style=3D"">
1997</option>
 <option value=3D"1998" style=3D"">
1998</option>
 <option value=3D"1999" style=3D"">
1999</option>
 <option value=3D"2000" style=3D"">
2000</option>
 <option value=3D"2001" style=3D"">
2001</option>
 <option value=3D"2002" style=3D"">
2002</option>
 <option value=3D"2003" style=3D"">
2003</option>
 <option value=3D"2004" style=3D"">
2004</option>
 <option value=3D"2005" style=3D"">
2005</option>
 <option value=3D"2006" style=3D"">
2006</option>
 <option value=3D"2007" style=3D"">
2007</option>
 <option value=3D"2008" style=3D"">
2008</option>
 <option value=3D"2009" style=3D"">
2009</option>
 <option value=3D"2010" style=3D"">
2010</option>
 <option value=3D"2011" style=3D"">
2011</option>
 <option value=3D"2012" style=3D"">
2012</option>
 <option value=3D"2013" style=3D"">
2013</option>
 <option value=3D"2014" style=3D"">
2014</option>
 <option value=3D"2015" style=3D"">
2015</option>
 <option value=3D"2016" style=3D"">
2016</option>
 <option value=3D"2017" style=3D"">
2017</option>
 <option value=3D"2018" style=3D"">
2018</option>
 <option value=3D"2019" selected=3D"" style=3D"">
2019</option>
 <option value=3D"2020" style=3D"">
2020</option>
 <option value=3D"2021" style=3D"">
2021</option>
 <option value=3D"2022" style=3D"">
2022</option>
 <option value=3D"2023" style=3D"">
2023</option>
 <option value=3D"2024" style=3D"">
2024</option>
 <option value=3D"2025" style=3D"">
2025</option>
 <option value=3D"2026" style=3D"">
2026</option>
 <option value=3D"2027" style=3D"">
2027</option>
 <option value=3D"2028" style=3D"">
2028</option>
 <option value=3D"2029" style=3D"">
2029</option>
 <option value=3D"2030" style=3D"">
2030</option>
 <option value=3D"2031" style=3D"">
2031</option>
 <option value=3D"2032" style=3D"">
2032</option>
 <option value=3D"2033" style=3D"">
2033</option>
 <option value=3D"2034" style=3D"">
2034</option>
 <option value=3D"2035" style=3D"">
2035</option>
 <option value=3D"2036" style=3D"">
2036</option>
 <option value=3D"2037" style=3D"">
2037</option>
 <option value=3D"2038" style=3D"">
2038</option>
 <option value=3D"2039" style=3D"">
2039</option>
 <option value=3D"2040" style=3D"">
2040</option>
 <option value=3D"2041" style=3D"">
2041</option>
 <option value=3D"2042" style=3D"">
2042</option>
 <option value=3D"2043" style=3D"">
2043</option>
 <option value=3D"2044" style=3D"">
2044</option>
 <option value=3D"2045" style=3D"">
2045</option>
 <option value=3D"2046" style=3D"">
2046</option>
 <option value=3D"2047" style=3D"">
2047</option>
 <option value=3D"2048" style=3D"">
2048</option>
 <option value=3D"2049" style=3D"">
2049</option>
 <option value=3D"2050" style=3D"">
2050</option>
 <option value=3D"2051" style=3D"">
2051</option>
 <option value=3D"2052" style=3D"">
2052</option>
 <option value=3D"2053" style=3D"">
2053</option>
 <option value=3D"2054" style=3D"">
2054</option>
 <option value=3D"2055" style=3D"">
2055</option>
 <option value=3D"2056" style=3D"">
2056</option>
 <option value=3D"2057" style=3D"">
2057</option>
 <option value=3D"2058" style=3D"">
2058</option>
 <option value=3D"2059" style=3D"">
2059</option>
 <option value=3D"2060" style=3D"">
2060</option>
 <option value=3D"2061" style=3D"">
2061</option>
 <option value=3D"2062" style=3D"">
2062</option>
 <option value=3D"2063" style=3D"">
2063</option>
 <option value=3D"2064" style=3D"">
2064</option>
 <option value=3D"2065" style=3D"">
2065</option>
 <option value=3D"2066" style=3D"">
2066</option>
 <option value=3D"2067" style=3D"">
2067</option>
 <option value=3D"2068" style=3D"">
2068</option>
 <option value=3D"2069" style=3D"">
2069</option>
</select>
 </div>
</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-text" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_74766472" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Tratamiento Realizado (si corresponde) </div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-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"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-checkbox" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1219705969" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Derivaci=F3n a otro Prestador Domiciliario </div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
S=F3lo llene esta secci=F3n si es m=E9dico y solicita la visita de otro prestador del equipo</div>
</label>
<ul class=3D"ss-choices" role=3D"group" aria-label=3D"Derivaci=F3n a otro Prestador Domiciliario S=F3lo llene esta secci=F3n si es m=E9dico y solicita la visita de otro prestador del equipo " style=3D"list-style:none; padding:0; margin:.5em 0 0">
<li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled=3D"" value=3D"ENFERMERA" id=3D"group_503039759_1" role=3D"checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
ENFERMERA</span>
 </label>
</li>
<li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled=3D"" value=3D"TENS" id=3D"group_503039759_2" role=3D"checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
TENS</span>
 </label>
</li>
<li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled=3D"" value=3D"NUTRICIONISTA" id=3D"group_503039759_3" role=3D"checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
NUTRICIONISTA</span>
 </label>
</li>
<li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled=3D"" value=3D"KINESIOLOGO" id=3D"group_503039759_4" role=3D"checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
KINESIOLOGO</span>
 </label>
</li>
<li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled=3D"" value=3D"PSICOLOGO" id=3D"group_503039759_5" role=3D"checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
PSICOLOGO</span>
 </label>
</li>
</ul>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style==3D"margin:12px 0; max-width:100%">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-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"ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A">
</div>
</div>
</div>
</div>
<br>
</form>
</div>
</div>
</td>
</tr>
<tr height=3D"24px">
</tr>
</tbody>
</table>
</div>
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%" role=3D"presentation" style=3D"max-width:672px; min-width:154px">
<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">
Crea tu propio formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
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