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<div id="AppleMailSignature" dir="ltr">
Enviado desde mi iPhone</div>

<div dir="ltr">
<br>

Inicio del mensaje reenviado:<br>

<br>

</div>

<blockquote type="cite">

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<b>
De:</b>
 Katherine Morales Cortes &lt;<a href="mailto:katherine.mcortes.md@outlook.com">
katherine.mcortes.md@outlook.com</a>
&gt;<br>

<b>
Fecha:</b>
 19 de abril de 2019, 21:06:22 CLT<br>

<b>
Para:</b>
 &quot;<a href="mailto:Coordinadora@telemed-chile.cl">
Coordinadora@telemed-chile.cl</a>
&quot; &lt;<a href="mailto:Coordinadora@telemed-chile.cl">
Coordinadora@telemed-chile.cl</a>
&gt;<br>

<b>
Cc:</b>
 &quot;<a href="mailto:claritamamani@telemed-chile.cl">
claritamamani@telemed-chile.cl</a>
&quot; &lt;<a href="mailto:claritamamani@telemed-chile.cl">
claritamamani@telemed-chile.cl</a>
&gt;, &quot;<a href="mailto:informeges@telemed-chile.cl">
informeges@telemed-chile.cl</a>

<a href="mailto:pamelafajardo@telemed-chile.cl">
pamelafajardo@telemed-chile.cl</a>
 &quot; &lt;<a href="mailto:informeges@telemed-chile.cl">
informeges@telemed-chile.cl</a>

<a href="mailto:pamelafajardo@telemed-chile.cl">
pamelafajardo@telemed-chile.cl</a>
 &gt;<br>

<b>
Asunto:</b>
 <b>
MARCO VILLALOBOS 19/04/19</b>
<br>

<br>

</div>

</blockquote>

<blockquote type="cite">

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<br>

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<div>

<div style="font-family: Calibri, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">

ESTIMADOS:</div>

<div style="font-family: Calibri, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">

&nbsp;JUNTO CON SLUDAR REENVIO ATENCION DOMICILIARIA REALIZADA A DON MARCOS.</div>

<div style="font-family: Calibri, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">

SALUDOS CRDIALES&nbsp;</div>

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<font face="Calibri, sans-serif" color="#000000" style="font-size:11pt">
<b>
De:</b>
 Formularios de Google &lt;<a href="mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;<br>

<b>
Enviado:</b>
 sábado, 20 de abril de 2019 1:01 a.m.<br>

<b>
Para:</b>
 <a href="mailto:katherine.mcortes.md@outlook.com">
katherine.mcortes.md@outlook.com</a>
<br>

<b>
Asunto:</b>
 Registro de Atención Domiciliaria Oncovida</font>

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&nbsp;</div>

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<table border="0" cellpadding="0" cellspacing="0" width="100%" role="presentation" style="background-color:rgb(38,4,154)">

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<tr height="64px">

<td style="padding-left:24px">
<img alt="Formularios de Google" height="26px" width="143px" style="display:inline-block; margin:0; vertical-align:middle" src="https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>

</tr>

</tbody>

</table>

<div style="padding:24px; background-color:rgb(229,218,254)">

<div align="center" style="background-color:#fff; border-bottom:1px solid #e0e0e0; margin:0 auto; max-width:624px; min-width:154px; padding:0 24px">

<table align="center" cellpadding="0" cellspacing="0" width="100%" role="presentation" style="background-color:#fff">

<tbody>

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</td>

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<tr>

<td>

<div style="font-size:13px; line-height:18px; color:#424242; font-weight:700">
Gracias por rellenar
<a href="https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=mail_form_link">

Registro de Atención Domiciliaria Oncovida</a>
</div>

</td>

</tr>

<tr height="12px">

</tr>

<tr>

<td>

<div style="font-size:13px; line-height:18px; color:#424242">
Esto es lo que nos has enviado:</div>

</td>

</tr>

<tr>

<td>

<div class="ss-form-container" style="">

<div class="ss-form-heading" style="">

<h1 class="ss-form-title" dir="ltr" style="margin:.67em 0">
Registro de Atención Domiciliaria Oncovida</h1>

<div class="ss-form-desc ss-no-ignore-whitespace" style="font:inherit; width:99%; margin:0 0 1em; white-space:pre-wrap; word-wrap:break-word">

Este es el sistema de registro de atenciones domiciliarias de Oncovida. Debe ser llenado por el prestador individual, y debe realizarse un registro por cada visita domiciliaria. Si usted no es prestador de Oncovida por favor no llene este formulario. A continuación
 indique su correo electrónico.</div>

</div>

<div class="ss-form" style="">

<form action="" method="GET" id="ss-form" style="">
<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<label class="ss-q-item-label" for="emailAddress" style="">

<div class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

Dirección de correo electrónico <label for="emailAddress" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>

</label>

<div class="ss-q-text ss-printable-text-line" dir="auto" style="background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%">

<a href="mailto:katherine.mcortes.md@outlook.com">
katherine.mcortes.md@outlook.com</a>
</div>

</div>

</div>

</div>

<div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-embeddable-object-container" style="margin:12px 0; max-width:100%">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<h2 class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

</h2>

<div style="text-align:right">
<img class="ss-image" title="" alt="Imagen sin leyenda" style="width:78px; outline:none" src="https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ">
</div>

</div>

</div>

</div>

<br>

<div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-page-break" style="margin:12px 0">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<h2 class="ss-page-title" style="padding:0.4em; background-color:#eee">
Identificación del Prestador</h2>

<div class="ss-page-description ss-no-ignore-whitespace" dir="auto" style="white-space:pre-wrap; word-wrap:break-word">

Aquí debe ingresar sus datos personales</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<label class="ss-q-item-label" for="entry_579114469" style="">

<div class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

Primer Nombre y Apellido Paterno <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block; margin:.1em 0 .25em 0; color:#666">

</div>

</label>

<div class="ss-q-text" dir="auto" style="background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%">

KATHERINE MORALES </div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<label class="ss-q-item-label" for="entry_1276273985" style="">

<div class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

RUT <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block; margin:.1em 0 .25em 0; color:#666">

RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>

</label>

<div class="ss-q-text" dir="auto" style="background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%">

25184204-3</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-select" style="margin:12px 0">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<label class="ss-q-item-label" for="entry_133691676" style="">

<div class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

Tipo <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block; margin:.1em 0 .25em 0; color:#666">

Si asisten más de 1 prestador simultáneamente, cada uno debe hacer un registro independiente</div>

</label>
<select name="entry.133691676" disabled="" id="entry_133691676" aria-label="Tipo Si asisten más de 1 prestador simultáneamente, cada uno debe hacer un registro independiente " style="">
<option value="" style="">

</option>
 <option value="MEDICO" disabled="" selected="" style="">
MEDICO</option>

<option value="ENFERMERA/O" disabled="" style="">
ENFERMERA/O</option>
 <option value="TENS" disabled="" style="">

TENS</option>
 <option value="KINESIOLOGA/O" disabled="" style="">
KINESIOLOGA/O</option>

<option value="PSICOLOGO" disabled="" style="">
PSICOLOGO</option>
 <option value="NUTRICIONISTA" disabled="" style="">

NUTRICIONISTA</option>
</select>
 </div>

</div>

</div>

<br>

<div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-embeddable-object-container" style="margin:12px 0; max-width:100%">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<h2 class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

</h2>

<div style="text-align:right">
<img class="ss-image" title="" alt="Imagen sin leyenda" style="width:78px; outline:none" src="https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA">
</div>

</div>

</div>

</div>

<br>

<div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-page-break" style="margin:12px 0">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<h2 class="ss-page-title" style="padding:0.4em; background-color:#eee">
Identificación del Paciente</h2>

<div class="ss-page-description ss-no-ignore-whitespace" dir="auto" style="white-space:pre-wrap; word-wrap:break-word">

En esta sección debe ingresar los datos del paciente visitado</div>

</div>

</div>

</div>

<br>

<div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-section-header" style="margin:12px 0">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<h2 class="ss-section-title" style="background-color:#eee; padding:0.4em">
Datos Personales del Paciente</h2>

<div class="ss-section-description ss-no-ignore-whitespace" style="margin-top:0.5em; white-space:pre-wrap; word-wrap:break-word">

</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<label class="ss-q-item-label" for="entry_823811303" style="">

<div class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

Ingrese el Rut del Paciente <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block; margin:.1em 0 .25em 0; color:#666">

RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>

</label>

<div class="ss-q-text" dir="auto" style="background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%">

9015729-9</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<label class="ss-q-item-label" for="entry_1959365839" style="">

<div class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

Ingrese el Primer Nombre y Apellido Paterno del Paciente <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block; margin:.1em 0 .25em 0; color:#666">

</div>

</label>

<div class="ss-q-text" dir="auto" style="background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%">

MARCO VILLALOBOS</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-select" style="margin:12px 0">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<label class="ss-q-item-label" for="entry_545002227" style="">

<div class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

Previsión <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block; margin:.1em 0 .25em 0; color:#666">

</div>

</label>
<select name="entry.545002227" disabled="" id="entry_545002227" aria-label="Previsión  " style="">
<option value="" style="">

</option>
 <option value="BANMEDICA" disabled="" style="">
BANMEDICA</option>
 <option value="CAPREDENA" disabled="" style="">

CAPREDENA</option>
 <option value="COLMENA" disabled="" selected="" style="">
COLMENA
</option>
 <option value="CONSALUD" disabled="" style="">
CONSALUD</option>
 <option value="CRUZ BLANCA" disabled="" style="">

CRUZ BLANCA</option>
 <option value="DIPRECA" disabled="" style="">
DIPRECA</option>

<option value="FONASA" disabled="" style="">
FONASA</option>
 <option value="FUNDACION" disabled="" style="">

FUNDACION</option>
 <option value="ISAPRES DEL COBRE" disabled="" style="">
ISAPRES DEL COBRE
</option>
 <option value="NUEVA MASVIDA" disabled="" style="">
NUEVA MASVIDA</option>

<option value="VIDATRES" disabled="" style="">
VIDATRES</option>
 <option value="PARTICULAR" disabled="" style="">

PARTICULAR</option>
</select>
 </div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<label class="ss-q-item-label" for="entry_1900161356" style="">

<div class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

Ciudad <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block; margin:.1em 0 .25em 0; color:#666">

</div>

</label>

<div class="ss-q-text" dir="auto" style="background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%">

ARICA</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<label class="ss-q-item-label" for="entry_1298871758" style="">

<div class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

Comuna <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block; margin:.1em 0 .25em 0; color:#666">

</div>

</label>

<div class="ss-q-text" dir="auto" style="background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%">

ARICA</div>

</div>

</div>

</div>

<br>

<div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-embeddable-object-container" style="margin:12px 0; max-width:100%">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<h2 class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

</h2>

<div style="text-align:right">
<img class="ss-image" title="" alt="Imagen sin leyenda" style="width:78px; outline:none" src="https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ">
</div>

</div>

</div>

</div>

<br>

<div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-page-break" style="margin:12px 0">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<h2 class="ss-page-title" style="padding:0.4em; background-color:#eee">
Registro de la Atención Domiciliaria</h2>

<div class="ss-page-description ss-no-ignore-whitespace" dir="auto" style="white-space:pre-wrap; word-wrap:break-word">

En esta sección debe ingresar los datos de la atención domiciliaria</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-radio" style="margin:12px 0">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<label class="ss-q-item-label" for="entry_2073233714" style="">

<div class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

Tipo de Atención <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block; margin:.1em 0 .25em 0; color:#666">

</div>

</label>

<ul class="ss-choices" role="radiogroup" aria-label="Tipo de Atención  " style="list-style:none; padding:0; margin:.5em 0 0">

<li class="ss-choice-item" style="margin:0; line-height:1.3em; padding-bottom:.5em">

<label>
<span class="ss-choice-item-control goog-inline-block" style="display:inline-block">
<input type="radio" name="entry.1222378237" disabled="" checked="" value="Domicilio" id="group_1222378237_1" role="radio" class="ss-q-radio" aria-label="Domicilio" style="">
</span>

<span class="ss-choice-label" style="">
Domicilio</span>
 </label>
</li>
<li class="ss-choice-item" style="margin:0; line-height:1.3em; padding-bottom:.5em">

<label>
<span class="ss-choice-item-control goog-inline-block" style="display:inline-block">
<input type="radio" name="entry.1222378237" disabled="" value="Ambulatorio" id="group_1222378237_2" role="radio" class="ss-q-radio" aria-label="Ambulatorio" style="">
</span>

<span class="ss-choice-label" style="">
Ambulatorio</span>
 </label>
</li>
</ul>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-date" style="margin:12px 0">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<label class="ss-q-item-label" for="entry_1705849412" style="">

<div class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

Fecha de la Atención <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block; margin:.1em 0 .25em 0; color:#666">

</div>

</label>

<div class="ss-q-date" role="group" aria-label="Fecha de la Atención  " style="">

<div class="ss-datetime-box goog-inline-block" role="group" style="border:1px solid #dcdcdc; margin-right:2em; min-height:32px; padding-left:3px; vertical-align:middle; margin:4px 3px; display:inline-block">

<select name="entry.1705849412_day" disabled="" class="ss-day-dropdown" id="entry.1705849412_day" aria-label="Día del mes" style="">
<option value="" style="">

Día</option>
 <option value="1" style="">
1</option>
 <option value="2" style="">
2</option>

<option value="3" style="">
3</option>
 <option value="4" style="">
4</option>
 <option value="5" style="">

5</option>
 <option value="6" style="">
6</option>
 <option value="7" style="">
7</option>

<option value="8" style="">
8</option>
 <option value="9" style="">
9</option>
 <option value="10" style="">

10</option>
 <option value="11" style="">
11</option>
 <option value="12" style="">
12
</option>
 <option value="13" style="">
13</option>
 <option value="14" style="">
14</option>

<option value="15" style="">
15</option>
 <option value="16" style="">
16</option>
 <option value="17" style="">

17</option>
 <option value="18" style="">
18</option>
 <option value="19" selected="" style="">

19</option>
 <option value="20" style="">
20</option>
 <option value="21" style="">
21
</option>
 <option value="22" style="">
22</option>
 <option value="23" style="">
23</option>

<option value="24" style="">
24</option>
 <option value="25" style="">
25</option>
 <option value="26" style="">

26</option>
 <option value="27" style="">
27</option>
 <option value="28" style="">
28
</option>
 <option value="29" style="">
29</option>
 <option value="30" style="">
30</option>

<option value="31" style="">
31</option>
</select>
 <select name="entry.1705849412_month" disabled="" class="ss-month-dropdown" id="entry.1705849412_month" aria-label="Mes" style="">
<option value="" style="">

Mes</option>
 <option value="1" style="">
enero</option>
 <option value="2" style="">

febrero</option>
 <option value="3" style="">
marzo</option>
 <option value="4" selected="" style="">

abril</option>
 <option value="5" style="">
mayo</option>
 <option value="6" style="">

junio</option>
 <option value="7" style="">
julio</option>
 <option value="8" style="">

agosto</option>
 <option value="9" style="">
septiembre</option>
 <option value="10" style="">

octubre</option>
 <option value="11" style="">
noviembre</option>
 <option value="12" style="">

diciembre</option>
</select>
 <select name="entry.1705849412_year" disabled="" id="entry.1705849412_year" aria-label="Año" style="">
<option value="" style="">

Año</option>
 <option value="1896" style="">
1896</option>
 <option value="1897" style="">

1897</option>
 <option value="1898" style="">
1898</option>
 <option value="1899" style="">

1899</option>
 <option value="1900" style="">
1900</option>
 <option value="1901" style="">

1901</option>
 <option value="1902" style="">
1902</option>
 <option value="1903" style="">

1903</option>
 <option value="1904" style="">
1904</option>
 <option value="1905" style="">

1905</option>
 <option value="1906" style="">
1906</option>
 <option value="1907" style="">

1907</option>
 <option value="1908" style="">
1908</option>
 <option value="1909" style="">

1909</option>
 <option value="1910" style="">
1910</option>
 <option value="1911" style="">

1911</option>
 <option value="1912" style="">
1912</option>
 <option value="1913" style="">

1913</option>
 <option value="1914" style="">
1914</option>
 <option value="1915" style="">

1915</option>
 <option value="1916" style="">
1916</option>
 <option value="1917" style="">

1917</option>
 <option value="1918" style="">
1918</option>
 <option value="1919" style="">

1919</option>
 <option value="1920" style="">
1920</option>
 <option value="1921" style="">

1921</option>
 <option value="1922" style="">
1922</option>
 <option value="1923" style="">

1923</option>
 <option value="1924" style="">
1924</option>
 <option value="1925" style="">

1925</option>
 <option value="1926" style="">
1926</option>
 <option value="1927" style="">

1927</option>
 <option value="1928" style="">
1928</option>
 <option value="1929" style="">

1929</option>
 <option value="1930" style="">
1930</option>
 <option value="1931" style="">

1931</option>
 <option value="1932" style="">
1932</option>
 <option value="1933" style="">

1933</option>
 <option value="1934" style="">
1934</option>
 <option value="1935" style="">

1935</option>
 <option value="1936" style="">
1936</option>
 <option value="1937" style="">

1937</option>
 <option value="1938" style="">
1938</option>
 <option value="1939" style="">

1939</option>
 <option value="1940" style="">
1940</option>
 <option value="1941" style="">

1941</option>
 <option value="1942" style="">
1942</option>
 <option value="1943" style="">

1943</option>
 <option value="1944" style="">
1944</option>
 <option value="1945" style="">

1945</option>
 <option value="1946" style="">
1946</option>
 <option value="1947" style="">

1947</option>
 <option value="1948" style="">
1948</option>
 <option value="1949" style="">

1949</option>
 <option value="1950" style="">
1950</option>
 <option value="1951" style="">

1951</option>
 <option value="1952" style="">
1952</option>
 <option value="1953" style="">

1953</option>
 <option value="1954" style="">
1954</option>
 <option value="1955" style="">

1955</option>
 <option value="1956" style="">
1956</option>
 <option value="1957" style="">

1957</option>
 <option value="1958" style="">
1958</option>
 <option value="1959" style="">

1959</option>
 <option value="1960" style="">
1960</option>
 <option value="1961" style="">

1961</option>
 <option value="1962" style="">
1962</option>
 <option value="1963" style="">

1963</option>
 <option value="1964" style="">
1964</option>
 <option value="1965" style="">

1965</option>
 <option value="1966" style="">
1966</option>
 <option value="1967" style="">

1967</option>
 <option value="1968" style="">
1968</option>
 <option value="1969" style="">

1969</option>
 <option value="1970" style="">
1970</option>
 <option value="1971" style="">

1971</option>
 <option value="1972" style="">
1972</option>
 <option value="1973" style="">

1973</option>
 <option value="1974" style="">
1974</option>
 <option value="1975" style="">

1975</option>
 <option value="1976" style="">
1976</option>
 <option value="1977" style="">

1977</option>
 <option value="1978" style="">
1978</option>
 <option value="1979" style="">

1979</option>
 <option value="1980" style="">
1980</option>
 <option value="1981" style="">

1981</option>
 <option value="1982" style="">
1982</option>
 <option value="1983" style="">

1983</option>
 <option value="1984" style="">
1984</option>
 <option value="1985" style="">

1985</option>
 <option value="1986" style="">
1986</option>
 <option value="1987" style="">

1987</option>
 <option value="1988" style="">
1988</option>
 <option value="1989" style="">

1989</option>
 <option value="1990" style="">
1990</option>
 <option value="1991" style="">

1991</option>
 <option value="1992" style="">
1992</option>
 <option value="1993" style="">

1993</option>
 <option value="1994" style="">
1994</option>
 <option value="1995" style="">

1995</option>
 <option value="1996" style="">
1996</option>
 <option value="1997" style="">

1997</option>
 <option value="1998" style="">
1998</option>
 <option value="1999" style="">

1999</option>
 <option value="2000" style="">
2000</option>
 <option value="2001" style="">

2001</option>
 <option value="2002" style="">
2002</option>
 <option value="2003" style="">

2003</option>
 <option value="2004" style="">
2004</option>
 <option value="2005" style="">

2005</option>
 <option value="2006" style="">
2006</option>
 <option value="2007" style="">

2007</option>
 <option value="2008" style="">
2008</option>
 <option value="2009" style="">

2009</option>
 <option value="2010" style="">
2010</option>
 <option value="2011" style="">

2011</option>
 <option value="2012" style="">
2012</option>
 <option value="2013" style="">

2013</option>
 <option value="2014" style="">
2014</option>
 <option value="2015" style="">

2015</option>
 <option value="2016" style="">
2016</option>
 <option value="2017" style="">

2017</option>
 <option value="2018" style="">
2018</option>
 <option value="2019" selected="" style="">

2019</option>
 <option value="2020" style="">
2020</option>
 <option value="2021" style="">

2021</option>
 <option value="2022" style="">
2022</option>
 <option value="2023" style="">

2023</option>
 <option value="2024" style="">
2024</option>
 <option value="2025" style="">

2025</option>
 <option value="2026" style="">
2026</option>
 <option value="2027" style="">

2027</option>
 <option value="2028" style="">
2028</option>
 <option value="2029" style="">

2029</option>
 <option value="2030" style="">
2030</option>
 <option value="2031" style="">

2031</option>
 <option value="2032" style="">
2032</option>
 <option value="2033" style="">

2033</option>
 <option value="2034" style="">
2034</option>
 <option value="2035" style="">

2035</option>
 <option value="2036" style="">
2036</option>
 <option value="2037" style="">

2037</option>
 <option value="2038" style="">
2038</option>
 <option value="2039" style="">

2039</option>
 <option value="2040" style="">
2040</option>
 <option value="2041" style="">

2041</option>
 <option value="2042" style="">
2042</option>
 <option value="2043" style="">

2043</option>
 <option value="2044" style="">
2044</option>
 <option value="2045" style="">

2045</option>
 <option value="2046" style="">
2046</option>
 <option value="2047" style="">

2047</option>
 <option value="2048" style="">
2048</option>
 <option value="2049" style="">

2049</option>
 <option value="2050" style="">
2050</option>
 <option value="2051" style="">

2051</option>
 <option value="2052" style="">
2052</option>
 <option value="2053" style="">

2053</option>
 <option value="2054" style="">
2054</option>
 <option value="2055" style="">

2055</option>
 <option value="2056" style="">
2056</option>
 <option value="2057" style="">

2057</option>
 <option value="2058" style="">
2058</option>
 <option value="2059" style="">

2059</option>
 <option value="2060" style="">
2060</option>
 <option value="2061" style="">

2061</option>
 <option value="2062" style="">
2062</option>
 <option value="2063" style="">

2063</option>
 <option value="2064" style="">
2064</option>
 <option value="2065" style="">

2065</option>
 <option value="2066" style="">
2066</option>
 <option value="2067" style="">

2067</option>
 <option value="2068" style="">
2068</option>
 <option value="2069" style="">

2069</option>
</select>
 </div>

</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-time" style="margin:12px 0; font:inherit">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<label class="ss-q-item-label" for="entry_206244955" style="">

<div class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

Hora de la Atención <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block; margin:.1em 0 .25em 0; color:#666">

</div>

</label>

<div class="ss-q-time" style="">

<div class="ss-datetime-box goog-inline-block" dir="ltr" style="border:1px solid #dcdcdc; margin-right:2em; min-height:32px; padding-left:3px; vertical-align:middle; margin:4px 3px; display:inline-block">

<select name="entry.206244955_hour" disabled="" id="entry.206244955_hour" aria-label="Hora" style="">
<option value="" style="">

h</option>
 <option value="00" style="">
00</option>
 <option value="01" style="">
01
</option>
 <option value="02" style="">
02</option>
 <option value="03" style="">
03</option>

<option value="04" style="">
04</option>
 <option value="05" style="">
05</option>
 <option value="06" style="">

06</option>
 <option value="07" style="">
07</option>
 <option value="08" style="">
08
</option>
 <option value="09" style="">
09</option>
 <option value="10" style="">
10</option>

<option value="11" style="">
11</option>
 <option value="12" style="">
12</option>
 <option value="13" style="">

13</option>
 <option value="14" style="">
14</option>
 <option value="15" style="">
15
</option>
 <option value="16" style="">
16</option>
 <option value="17" selected="" style="">

17</option>
 <option value="18" style="">
18</option>
 <option value="19" style="">
19
</option>
 <option value="20" style="">
20</option>
 <option value="21" style="">
21</option>

<option value="22" style="">
22</option>
 <option value="23" style="">
23</option>
</select>
 :
<select name="entry.206244955_minute" disabled="" id="entry.206244955_minute" aria-label="Minuto" style="">
<option value="" style="">

min</option>
 <option value="00" selected="" style="">
00</option>
 <option value="01" style="">

01</option>
 <option value="02" style="">
02</option>
 <option value="03" style="">
03
</option>
 <option value="04" style="">
04</option>
 <option value="05" style="">
05</option>

<option value="06" style="">
06</option>
 <option value="07" style="">
07</option>
 <option value="08" style="">

08</option>
 <option value="09" style="">
09</option>
 <option value="10" style="">
10
</option>
 <option value="11" style="">
11</option>
 <option value="12" style="">
12</option>

<option value="13" style="">
13</option>
 <option value="14" style="">
14</option>
 <option value="15" style="">

15</option>
 <option value="16" style="">
16</option>
 <option value="17" style="">
17
</option>
 <option value="18" style="">
18</option>
 <option value="19" style="">
19</option>

<option value="20" style="">
20</option>
 <option value="21" style="">
21</option>
 <option value="22" style="">

22</option>
 <option value="23" style="">
23</option>
 <option value="24" style="">
24
</option>
 <option value="25" style="">
25</option>
 <option value="26" style="">
26</option>

<option value="27" style="">
27</option>
 <option value="28" style="">
28</option>
 <option value="29" style="">

29</option>
 <option value="30" style="">
30</option>
 <option value="31" style="">
31
</option>
 <option value="32" style="">
32</option>
 <option value="33" style="">
33</option>

<option value="34" style="">
34</option>
 <option value="35" style="">
35</option>
 <option value="36" style="">

36</option>
 <option value="37" style="">
37</option>
 <option value="38" style="">
38
</option>
 <option value="39" style="">
39</option>
 <option value="40" style="">
40</option>

<option value="41" style="">
41</option>
 <option value="42" style="">
42</option>
 <option value="43" style="">

43</option>
 <option value="44" style="">
44</option>
 <option value="45" style="">
45
</option>
 <option value="46" style="">
46</option>
 <option value="47" style="">
47</option>

<option value="48" style="">
48</option>
 <option value="49" style="">
49</option>
 <option value="50" style="">

50</option>
 <option value="51" style="">
51</option>
 <option value="52" style="">
52
</option>
 <option value="53" style="">
53</option>
 <option value="54" style="">
54</option>

<option value="55" style="">
55</option>
 <option value="56" style="">
56</option>
 <option value="57" style="">

57</option>
 <option value="58" style="">
58</option>
 <option value="59" style="">
59
</option>
</select>

<div class="ss-datetime-box-spacer goog-inline-block" style="height:32px; vertical-align:middle; display:inline-block">

</div>

</div>

</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-select" style="margin:12px 0">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<label class="ss-q-item-label" for="entry_1747608258" style="">

<div class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

Performance Status ECOG del Paciente <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block; margin:.1em 0 .25em 0; color:#666">

</div>

</label>
<select name="entry.1747608258" disabled="" id="entry_1747608258" aria-label="Performance Status ECOG del Paciente  " style="">
<option value="" style="">

</option>
 <option value="0" disabled="" selected="" style="">
0</option>
 <option value="1" disabled="" style="">

1</option>
 <option value="2" disabled="" style="">
2</option>
 <option value="3" disabled="" style="">

3</option>
 <option value="4" disabled="" style="">
4</option>
</select>
 </div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-scale" style="margin:12px 0; overflow-x:auto">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<label class="ss-q-item-label" for="entry_1716090865" style="">

<div class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

Escala Dolor EVA Actual </div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block; margin:.1em 0 .25em 0; color:#666">

</div>

</label>

<table border="0" cellpadding="5" cellspacing="0" id="entry_1421689035" style="">

<tbody>

<tr aria-hidden="true" style="">

<td class="ss-scalenumbers" style="text-align:center">
</td>

<td class="ss-scalenumbers" style="text-align:center">
<label class="ss-scalenumber" for="group_1421689035_1" style="display:block; padding:0.5em 0 .5em">
0</label>
</td>

<td class="ss-scalenumbers" style="text-align:center">
<label class="ss-scalenumber" for="group_1421689035_2" style="display:block; padding:0.5em 0 .5em">
1</label>
</td>

<td class="ss-scalenumbers" style="text-align:center">
<label class="ss-scalenumber" for="group_1421689035_3" style="display:block; padding:0.5em 0 .5em">
2</label>
</td>

<td class="ss-scalenumbers" style="text-align:center">
<label class="ss-scalenumber" for="group_1421689035_4" style="display:block; padding:0.5em 0 .5em">
3</label>
</td>

<td class="ss-scalenumbers" style="text-align:center">
<label class="ss-scalenumber" for="group_1421689035_5" style="display:block; padding:0.5em 0 .5em">
4</label>
</td>

<td class="ss-scalenumbers" style="text-align:center">
<label class="ss-scalenumber" for="group_1421689035_6" style="display:block; padding:0.5em 0 .5em">
5</label>
</td>

<td class="ss-scalenumbers" style="text-align:center">
<label class="ss-scalenumber" for="group_1421689035_7" style="display:block; padding:0.5em 0 .5em">
6</label>
</td>

<td class="ss-scalenumbers" style="text-align:center">
<label class="ss-scalenumber" for="group_1421689035_8" style="display:block; padding:0.5em 0 .5em">
7</label>
</td>

<td class="ss-scalenumbers" style="text-align:center">
<label class="ss-scalenumber" for="group_1421689035_9" style="display:block; padding:0.5em 0 .5em">
8</label>
</td>

<td class="ss-scalenumbers" style="text-align:center">
<label class="ss-scalenumber" for="group_1421689035_10" style="display:block; padding:0.5em 0 .5em">
9</label>
</td>

<td class="ss-scalenumbers" style="text-align:center">
<label class="ss-scalenumber" for="group_1421689035_11" style="display:block; padding:0.5em 0 .5em">
10</label>
</td>

<td class="ss-scalenumbers" style="text-align:center">
</td>

</tr>

<tr role="radiogroup" aria-label="Escala Dolor EVA Actual  Selecciona un valor en el intervalo de 0 a 10 ." style="">

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Masculino de 56 años de edad. APP: Hipertensión Arterial sin tratamiento farmacológico dado que mantiene cifras normales de TA, DM tipo 2 tratada con Metformina (750mg) 1 comprimido en la noche y HPB para lo que toma Gotely (0,4mg) 1 Capsula am diario. RAM:
 no refiere. Hábitos tóxicos: tabaquismo 5 cigarros al día por 18 años( ex fumador) Cirugías: Apendicectomía( aprox 30 años), RTU (2014) colecistectomía (2016) Alimentación actual: 3 comidas principales mas 2 colaciones (pauta de nutricionista) APF: CA gástrico
 papá Diagnóstico actual: Carcinoma Escamoso de Amígala Izquierda tratado con sesiones de radioterapias mas quimioterapias. Síntomas actuales: refiere sequedad bucal, saliva espesa por lo que toma con mayor frecuencia agua( pequeños sorbos) , pero esto no le
 impide alimentarse ni conversar. Anímicamente bien, sonríe durante la entrevista, niega anhedonia, labilidad emocional, insomnio. Menciona que se encuentra con ganas de hace cosas y tranquilo. Afebril, niega dolor por ello no ha tenido necesidad de administrarse
 los analgésicos previamente indicados. Necesidades fisiológicas conservadas. Menciona que a fin de mes tiene hora con OTORRINO. Además para la próxima está coordinada hora con kinesióloga y nutricionista
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Mucosas: normocoloreadas sequedad escasa en mucosa oral, resto normal. ACV: rr2tss, llene capilar menor a 2 seg. TA: 125/76 mmHg fc: 56 por min. AR: mp presente sin ruidos agregados, no uso de musculatura accesoria ni cianosis. SAT: 98% SNC: vigil orientado
 en tiempo espacio y persona, sin signos de focalización neurológica. Cincinnati negativo. Pupilas isocóricas y normo reactivas. Orofaringe: faringe coloracion normal, sin exudado, sin otras alteraciones evidentes( al paciente se le dificulta un poco cooperar
 porque se le seca la boca) Piel: hiperpigmentación y sequedad en área del cuello, Región cervical: aumento de volumen de 10x 8 cm aprox de diámetro, ovoideo, sin cambios de coloración ni signos inflamatorios, compatible con lipoma
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Carcinoma Escamoso de Amígala Izquierda </div>

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Psicoeducación a paciente. Evitar la exposición al sol, usar bloqueador solar. Paracetamol ( 1 gr) cada 8 horas SOS (explicado y entendido por paciente y esposa) Aplicar cicaplast en área del cuello 3 veces al día. Se indica balsamo labial aplicar cada vez
 que sea necesario. Además se recomienda evitar la ingesta de alimentos citricos para aumentar sequedad bucal. Se explica que en control con Otorrino debe explicar lo de la sequedad bucal y consultar si se puede indicar algún tto. Continuar uso de tratamiento
 patologías crónicas. Si signos y síntomas de alarma acudir a urgencia correspondiente.
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Medicamentos Indicados </div>

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Fecha aproximada del Próximo Control con usted </div>

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junio</option>
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<div dir="auto" class="ss-item  ss-embeddable-object-container" style="margin:12px 0; max-width:100%">

<div class="ss-form-entry" style="margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">

<h2 class="ss-q-title" style="display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">

</h2>

<div style="text-align:right">
<img class="ss-image" title="" alt="Imagen sin leyenda" style="width:78px; outline:none" src="https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A">
</div>

</div>

</div>

</div>

<br>

</form>

</div>

</div>

</td>

</tr>

<tr height="24px">

</tr>

</tbody>

</table>

</div>

<table align="center" cellpadding="0" cellspacing="0" width="100%" role="presentation" style="max-width:672px; min-width:154px">

<tbody>

<tr height="24px">

<td>
</td>

</tr>

<tr>

<td>
<a href="https://docs.google.com/forms?usp=mail_form_link" style="color:#424242; font-size:13px">
Crea tu propio formulario de Google</a>
</td>

</tr>

</tbody>

</table>

</div>

</div>

</div>

</div>

</blockquote>

</body>

</html>

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