<div dir=3D"ltr">
<br>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class==3D"gmail_attr">
---------- Forwarded message ---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Formularios de Google</strong>
 <span dir=3D"auto">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: s=C3=A1b., 27 jul. 2019 a las 19:20<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:elizabethcorreadiaz@gmail.com">
elizabethcorreadiaz@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Formularios de Google" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por rellenar <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp==3Dmail_form_link" target=3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_-7496483628412200877ss-form-container">
<div class=3D"m_-7496483628412200877ss-form-heading">
<h1 class=3D"m_-7496483628412200877ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_-7496483628412200877ss-form-desc m_-7496483628412200877ss-no-ignore-whitespace" style=3D"font:inherit;width:99%;margin:0 0 1em;white-space:pre-wrap;word-wrap:break-word">
Este es el sistema de registro de atenciones domiciliarias de Oncovida.   Debe ser llenado por el prestador individual, y debe realizarse un registro por cada visita domiciliaria.   Si usted no es prestador de Oncovida por favor no llene este formulario.   A continuaci=C3=B3n indique su correo electr=C3=B3nico.</div>
</div>
<div class=3D"m_-7496483628412200877ss-form">
<form method=3D"GET" id=3D"m_-7496483628412200877ss-form" target=3D"_blank">
<br>
<div class=3D"m_-7496483628412200877ss-form-question m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-item-required m_-7496483628412200877ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7496483628412200877ss-q-item-label" for=3D"m_-7496483628412200877emailAddress">
<div class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Direcci=C3=B3n de correo electr=C3=B3nico<label for=3D"m_-7496483628412200877emailAddress">
</label>
<span class=3D"m_-7496483628412200877ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_-7496483628412200877ss-q-text m_-7496483628412200877ss-printable-text-line" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
<a href=3D"mailto:elizabethcorreadiaz@gmail.com" target=3D"_blank">
elizabethcorreadiaz@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_-7496483628412200877ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/00-FWRRIiJNpjLIXj1QrTLVceHhiPxWpIN-K4cI0enEtAvmFFnvOHRJTMz5Lq8yFpMHz7WvBnNdiNVchE6Snklpxxc7gIx3OoqTfn_sB2_iSp_6sx7Sr2pww-0pD" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-7496483628412200877ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_-7496483628412200877ss-page-description m_-7496483628412200877ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
Aqu=C3=AD debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877ss-form-question m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-item-required m_-7496483628412200877ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7496483628412200877ss-q-item-label" for=3D"m_-7496483628412200877entry_579114469">
<div class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_-7496483628412200877itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7496483628412200877ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7496483628412200877ss-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%">
ELIZABETH CORREA</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877ss-form-question m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-item-required m_-7496483628412200877ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7496483628412200877ss-q-item-label" for=3D"m_-7496483628412200877entry_1276273985">
<div class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_-7496483628412200877itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7496483628412200877ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_-7496483628412200877ss-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%">
16203285-2</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877ss-form-question m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-item-required m_-7496483628412200877ss-select" style=3D"margin:12px 0">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7496483628412200877ss-q-item-label" for=3D"m_-7496483628412200877entry_133691676">
<div class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_-7496483628412200877itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7496483628412200877ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
Si asisten m=C3=A1s de 1 prestador simult=C3=A1neamente, cada uno debe hacer un registro independiente</div>
</label>
<select name=3D"entry.133691676" disabled id=3D"m_-7496483628412200877entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled selected>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_-7496483628412200877ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/mRJInQVKRU12r9blREv2jmlzETLT9JfIHWC0FaeXYfPraPFE9ebBRX8P_hmpfiBP6BNpOgjPBYU0zwBxYxgoLvjQ7EjfjoRTJ2_-8flTaiU_wC008XC8LpcEJ_Yp" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-7496483628412200877ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_-7496483628412200877ss-page-description m_-7496483628412200877ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-7496483628412200877ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_-7496483628412200877ss-section-description m_-7496483628412200877ss-no-ignore-whitespace" style=3D"margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877ss-form-question m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-item-required m_-7496483628412200877ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7496483628412200877ss-q-item-label" for=3D"m_-7496483628412200877entry_823811303">
<div class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_-7496483628412200877itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7496483628412200877ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_-7496483628412200877ss-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%">
13980180-6</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877ss-form-question m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-item-required m_-7496483628412200877ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7496483628412200877ss-q-item-label" for=3D"m_-7496483628412200877entry_1959365839">
<div class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente<label for=3D"m_-7496483628412200877itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7496483628412200877ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7496483628412200877ss-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%">
KATHERINE GONZALEZ</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877ss-form-question m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-item-required m_-7496483628412200877ss-select" style=3D"margin:12px 0">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7496483628412200877ss-q-item-label" for=3D"m_-7496483628412200877entry_545002227">
<div class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_-7496483628412200877itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7496483628412200877ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.545002227" disabled id=3D"m_-7496483628412200877entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
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CAPREDENA</option>
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COLMENA</option>
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CONSALUD</option>
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CRUZ BLANCA</option>
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DIPRECA</option>
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FONASA</option>
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FUNDACION</option>
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ISAPRES DEL COBRE</option>
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NUEVA MASVIDA</option>
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VIDATRES</option>
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PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877ss-form-question m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-item-required m_-7496483628412200877ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7496483628412200877ss-q-item-label" for=3D"m_-7496483628412200877entry_1900161356">
<div class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_-7496483628412200877itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7496483628412200877ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7496483628412200877ss-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%">
VALPARAISO</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877ss-form-question m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-item-required m_-7496483628412200877ss-text" style=3D"margin:12px 0">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7496483628412200877ss-q-item-label" for=3D"m_-7496483628412200877entry_1298871758">
<div class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_-7496483628412200877itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7496483628412200877ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7496483628412200877ss-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%">
VALPARAISO</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_-7496483628412200877ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/URytM0QWRGW_JEL0xQxvOLvwPRJIHyqlnKOm6ky9DRBfzvYVPaAngXV35GNHnaVG-dm9Orno4lr8sy8E-KB9tMrmIhFbVQiOPWy3vUclqRKAJ51dvLdhjBKgXdLO" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-7496483628412200877ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_-7496483628412200877ss-page-description m_-7496483628412200877ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos de la atenci=C3=B3n domiciliaria</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877ss-form-question m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-item-required m_-7496483628412200877ss-radio" style=3D"margin:12px 0">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7496483628412200877ss-q-item-label" for=3D"m_-7496483628412200877entry_2073233714">
<div class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_-7496483628412200877itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7496483628412200877ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_-7496483628412200877ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-7496483628412200877ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-7496483628412200877ss-choice-item-control m_-7496483628412200877goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_-7496483628412200877group_1222378237_1" class=3D"m_-7496483628412200877ss-q-radio">
</span>
<span class=3D"m_-7496483628412200877ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_-7496483628412200877ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-7496483628412200877ss-choice-item-control m_-7496483628412200877goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_-7496483628412200877group_1222378237_2" class=3D"m_-7496483628412200877ss-q-radio">
</span>
<span class=3D"m_-7496483628412200877ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877ss-form-question m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-item-required m_-7496483628412200877ss-date" style=3D"margin:12px 0">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7496483628412200877ss-q-item-label" for=3D"m_-7496483628412200877entry_1705849412">
<div class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha de la Atenci=C3=B3n<label for=3D"m_-7496483628412200877itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7496483628412200877ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7496483628412200877ss-q-date">
<div class=3D"m_-7496483628412200877ss-datetime-box m_-7496483628412200877goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name=3D"entry.1705849412_day" disabled class=3D"m_-7496483628412200877ss-day-dropdown" id=3D"m_-7496483628412200877entry.1705849412_day">
<option value=3D"">
D==C3=ADa</option>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
 <option value=3D"24">
24</option>
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25</option>
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26</option>
 <option value=3D"27">
27</option>
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28</option>
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29</option>
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30</option>
 <option value=3D"31">
31</option>
</select>
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<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
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febrero</option>
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marzo</option>
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abril</option>
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mayo</option>
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junio</option>
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julio</option>
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agosto</option>
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septiembre</option>
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octubre</option>
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noviembre</option>
 <option value=3D"12">
diciembre</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_-7496483628412200877entry.1705849412_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
 <option value=3D"1905">
1905</option>
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1906</option>
 <option value=3D"1907">
1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
 <option value=3D"1912">
1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
 <option value==3D"1932">
1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
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1958</option>
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1959</option>
 <option value==3D"1960">
1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
 <option value==3D"1972">
1972</option>
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1973</option>
 <option value==3D"1974">
1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
 <option value==3D"1984">
1984</option>
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1985</option>
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1986</option>
 <option value=3D"1987">
1987</option>
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1988</option>
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1989</option>
 <option value==3D"1990">
1990</option>
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1991</option>
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1992</option>
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1993</option>
 <option value==3D"1994">
1994</option>
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1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
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2009</option>
 <option value==3D"2010">
2010</option>
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2011</option>
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2012</option>
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2013</option>
 <option value==3D"2014">
2014</option>
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2015</option>
 <option value==3D"2016">
2016</option>
 <option value=3D"2017">
2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877ss-form-question m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-item-required m_-7496483628412200877ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7496483628412200877ss-q-item-label" for=3D"m_-7496483628412200877entry_206244955">
<div class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Hora de la Atenci=C3=B3n<label for=3D"m_-7496483628412200877itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7496483628412200877ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-7496483628412200877ss-q-time">
<div class=3D"m_-7496483628412200877ss-datetime-box m_-7496483628412200877goog-inline-block" dir=3D"ltr" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
<select name=3D"entry.206244955_hour" disabled id=3D"m_-7496483628412200877entry.206244955_hour">
<option value=3D"">
h</option>
<option value=3D"00">
00</option>
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01</option>
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02</option>
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03</option>
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04</option>
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05</option>
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06</option>
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07</option>
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08</option>
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09</option>
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10</option>
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11</option>
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12</option>
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13</option>
 <option value=3D"14">
14</option>
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15</option>
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16</option>
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17</option>
 <option value=3D"18">
18</option>
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19</option>
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20</option>
 <option value=3D"21">
21</option>
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22</option>
 <option value=3D"23">
23</option>
</select>
:<select name=3D"entry.206244955_minute" disabled id=3D"m_-7496483628412200877entry.206244955_minute">
<option value=3D"">
min</option>
<option value=3D"00">
00</option>
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01</option>
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02</option>
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04</option>
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05</option>
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06</option>
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07</option>
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08</option>
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09</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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32</option>
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33</option>
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34</option>
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35</option>
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36</option>
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37</option>
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38</option>
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39</option>
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40</option>
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41</option>
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42</option>
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43</option>
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44</option>
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45</option>
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46</option>
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47</option>
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48</option>
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49</option>
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50</option>
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51</option>
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52</option>
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53</option>
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54</option>
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55</option>
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56</option>
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57</option>
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58</option>
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59</option>
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</div>
</div>
</div>
</div>
</div>
</div>
<br>
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<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-item-required m_-7496483628412200877ss-select" style=3D"margin:12px 0">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7496483628412200877ss-q-item-label" for=3D"m_-7496483628412200877entry_1747608258">
<div class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_-7496483628412200877itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7496483628412200877ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.1747608258" disabled id=3D"m_-7496483628412200877entry_1747608258">
<option value=3D"">
</option>
<option value=3D"0" disabled>
0</option>
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1</option>
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2</option>
 <option value=3D"3" disabled>
3</option>
 <option value=3D"4" disabled>
4</option>
</select>
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</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877ss-form-question m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7496483628412200877ss-q-item-label" for=3D"m_-7496483628412200877entry_1716090865">
<div class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_-7496483628412200877entry_1421689035">
<tbody>
<tr>
<td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
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<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1421689035_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
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<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
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<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
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<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1421689035_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-7496483628412200877ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-7496483628412200877ss-scalerow m_-7496483628412200877ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class==3D"m_-7496483628412200877aria-todo">
</div>
</td>
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</div>
</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"1" id=3D"m_-7496483628412200877group_1421689035_2" class=3D"m_-7496483628412200877ss-q-radio">
</div>
</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"2" id=3D"m_-7496483628412200877group_1421689035_3" class==3D"m_-7496483628412200877ss-q-radio">
</div>
</td>
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<div class=3D"m_-7496483628412200877ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3" id=3D"m_-7496483628412200877group_1421689035_4" class=3D"m_-7496483628412200877ss-q-radio">
</div>
</td>
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<div class=3D"m_-7496483628412200877ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_-7496483628412200877group_1421689035_5" class=3D"m_-7496483628412200877ss-q-radio">
</div>
</td>
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<div class=3D"m_-7496483628412200877ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_-7496483628412200877group_1421689035_6" class=3D"m_-7496483628412200877ss-q-radio">
</div>
</td>
 <td class=3D"m_-7496483628412200877ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_-7496483628412200877ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_-7496483628412200877group_1421689035_7" class=3D"m_-7496483628412200877ss-q-radio">
</div>
</td>
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<div class=3D"m_-7496483628412200877ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"7" id=3D"m_-7496483628412200877group_1421689035_8" class=3D"m_-7496483628412200877ss-q-radio">
</div>
</td>
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<div class=3D"m_-7496483628412200877ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_-7496483628412200877group_1421689035_9" class=3D"m_-7496483628412200877ss-q-radio">
</div>
</td>
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<div class=3D"m_-7496483628412200877ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled checked value=3D"9" id=3D"m_-7496483628412200877group_1421689035_10" class=3D"m_-7496483628412200877ss-q-radio">
</div>
</td>
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<div class=3D"m_-7496483628412200877ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"10" id=3D"m_-7496483628412200877group_1421689035_11" class=3D"m_-7496483628412200877ss-q-radio">
</div>
</td>
<td class=3D"m_-7496483628412200877ss-scalerow m_-7496483628412200877ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_-7496483628412200877ss-form-question m_-7496483628412200877errorbox-good">
<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-7496483628412200877ss-q-item-label" for=3D"m_-7496483628412200877entry_2064050596">
<div class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=A1ximo</div>
<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_-7496483628412200877entry_1244707512">
<tbody>
<tr>
<td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1244707512_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-7496483628412200877ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1244707512_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-7496483628412200877ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-7496483628412200877ss-scalenumber" for=3D"m_-7496483628412200877group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-7496483628412200877ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-7496483628412200877ss-scalerow m_-7496483628412200877ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class==3D"m_-7496483628412200877aria-todo">
</div>
</td>
<td class=3D"m_-7496483628412200877ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_-7496483628412200877ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"0" id=3D"m_-7496483628412200877group_1244707512_1" class=3D"m_-7496483628412200877ss-q-radio">
</div>
</td>
 <td class=3D"m_-7496483628412200877ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_-7496483628412200877ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"1" id=3D"m_-7496483628412200877group_1244707512_2" class=3D"m_-7496483628412200877ss-q-radio">
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2</label>
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3</label>
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10</label>
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</td>
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PACIENTE EN CONDICIONES DE DOLOR AGUDO INTENSO EN HIPOGASTRIOREFIERE NO HABER PRESENTADO SINTOMATOLOGIA DESDE ULTIMA EVALUACION, SIN EMBARGO DURANTE LAS ULTIMAS 24 HRS COMIENZA CON CUADRO DE DOLOR ABDOMINAL TIPO COLICO DE MEDIANA INTENSIDAD QUE DURANTE LA NOCHE SE VUELVE DE INTENSIDAD MAYOR LO QUE GENERA NECESIDAD DE ATENCION DE URGENCIA DONDE SE DESCARTAN CUADROS DE URGENCIA QUIRURGICA Y SE INDICA ANALGESIA EV.=20HOY SE MANTIENE CON DOLOR INTENSO EN HIPOGASTRIO ASOCIADO ANAUSEAS Y EPIODIOS DE VOMITO BILIAR.=20SIN ESTUDIOS PARA CONTROL ONCOOGICO ACTUALES.TERCER DIA DE EVOLUCION DE FRACTURA PERONE DERECHO</div>
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NORMOCARDICA, NORMOTENSA, AFEBRIL, SA O2 99%PIEL SANA=20NEUROLOGICO: SIN DEFICIT FOCACARDIO NORMALPULMONAR MP +/+ SRA=20ABDOMEN: BLANDO DEPRESIBLE DOLOROSO EN HIPOGASTRIO SIN SIGNOS PERITONEALES, RHA + DEPOSICIONES NORMALES, REFIERE EPISODIOS DE VOMITO Y NAUSEASEXTREMIDADES SIN SIGNOS DE TVP, EXTREMIDAD INFERIOR DERECHA INMOVILIZADA CON BOTA ORTOPEDICA POR FX DE PERONE DE TRES DIAS DE EVOLUCION</div>
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Plan de Tratamiento e Indicaciones<label for=3D"m_-7496483628412200877itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-7496483628412200877ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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SE INDICA ANALGESIA IM POR 1 VEZ PARA ALIVIO INMEDIATO DE DOLORSE INDICA ANTIESPASMODICO ORAL ASOCIADO A ANTIHEMETICOSE INDICA QUE SI DOLOR PERSISTE DEBERA SER EVALUADO POR SERVICIO DE URGENCIA=20SE REDACTARA INFORME A ISAPRE NUEVA MAS VIDA PARA GESTIONAR CONTROLES SEMANALES POR CRISIS ACTUAL DE DOLOR ASOCIADO A CANCERCONTROL MEDICO, DE ENFERMERIA, PSICOLOGO DE MANERA INICIAL</div>
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Medicamentos Indicados</div>
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KETOROLACO IM X 1 VEZVIADIL COMPUESTO 35 GTS CADA 8 HRS X 5 DIASMETOCLOPRAMIDA 10 MG C/ 8 HRS X 5 DIASTRANSTEC 1/4 PARCHE CADA 72 HRS PARA MANEJO DE DOLOR </div>
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Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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D==C3=ADa</option>
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1</option>
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2</option>
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31</option>
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2056</option>
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2060</option>
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2065</option>
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2066</option>
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Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
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<br>
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Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_-7496483628412200877ss-q-help m_-7496483628412200877ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
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ENFERMERA</span>
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TENS</span>
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<span class=3D"m_-7496483628412200877ss-choice-label">
NUTRICIONISTA</span>
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KINESIOLOGO</span>
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PSICOLOGO</span>
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<div dir=3D"auto" class=3D"m_-7496483628412200877ss-item m_-7496483628412200877ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-7496483628412200877ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-7496483628412200877ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_-7496483628412200877ss-image" title=3D"" src=3D"https://lh5.googleusercontent.com/Bpur5zPteyG-bXtM-WNRuiLwTi8myvetX7lBkdjzbnQyqUlGcuv84zmWyU3x0Ua2-_WXX9PiJ2cMBOO0zhG2nHX7tXXPHH6_X8UTG8MZzIBwxETkF0a8JyZtuxSL" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</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" style=3D"max-width:672px;min-width:154px" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242;font-size:13px" target=3D"_blank">
Crea tu propio formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
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