<br>
<br>
---------- Mensaje reenviado ----------<br>
De: <b>
Google Forms</b>
 &lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;<br>
Fecha: lunes, 5 de agosto de 2019<br>
Asunto: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
Para: <a href=3D"mailto:md.eury@gmail.com">
md.eury@gmail.com</a>
<br>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Google Forms" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style==3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Thanks for filling out <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target=3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Here&#39;s what we got from you:</div>
</td>
</tr>
<tr>
<td>
<div>
<div>
<h1 dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div 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>
<form method=3D"GET" target=3D"_blank">
<br>
<div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Email address<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div 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:md.eury@gmail.com" target=3D"_blank">
md.eury@gmail.com</a>
</div>
</div>
</div>
</div>
<div>
<div dir=3D"auto" style=3D"margin:12px 0;max-width:100%">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img title=3D"" src=3D"https://lh3.googleusercontent.com/00-FWRRIiJNpjLIXj1QrTLVceHhiPxWpIN-K4cI0enEtAvmFFnvOHRJTMz5Lq8yFpMHz7WvBnNdiNVchE6Snklpxxc7gIx3OoqTfn_sB2_iSp_6sx7Sr2pww-0pD" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div 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>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div 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%">
Eury Gonzalez</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div 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 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%">
26220712-9</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div 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>
<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>
<div dir=3D"auto" style=3D"margin:12px 0;max-width:100%">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img title=3D"" src=3D"https://lh3.googleusercontent.com/mRJInQVKRU12r9blREv2jmlzETLT9JfIHWC0FaeXYfPraPFE9ebBRX8P_hmpfiBP6BNpOgjPBYU0zwBxYxgoLvjQ7EjfjoRTJ2_-8flTaiU_wC008XC8LpcEJ_Yp" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div 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>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div style=3D"margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word">
</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div 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 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%">
9100327-9</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div 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%">
Ingrid Garcia</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.545002227" disabled>
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled>
COLMENA</option>
 <option value=3D"CONSALUD" disabled>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value==3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled selected>
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled>
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div 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%">
Puerto Montt</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div 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%">
Puerto Montt</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0;max-width:100%">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img title=3D"" src=3D"https://lh6.googleusercontent.com/URytM0QWRGW_JEL0xQxvOLvwPRJIHyqlnKOm6ky9DRBfzvYVPaAngXV35GNHnaVG-dm9Orno4lr8sy8E-KB9tMrmIhFbVQiOPWy3vUclqRKAJ51dvLdhjBKgXdLO" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3==B3n Domiciliaria</h2>
<div 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>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio">
</span>
<span>
Domicilio</span>
</label>
</li>
 <li style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio">
</span>
<span>
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha de la Atenci=C3=B3n<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div>
<div style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name=3D"entry.1705849412_month" disabled>
<option value=3D"">
Month</option>
<option value=3D"1">
January</option>
 <option value=3D"2">
February</option>
 <option value=3D"3">
March</option>
 <option value=3D"4">
April</option>
 <option value=3D"5">
May</option>
 <option value=3D"6">
June</option>
 <option value=3D"7">
July</option>
 <option value=3D"8" selected>
August</option>
 <option value=3D"9">
September</option>
 <option value=3D"10">
October</option>
 <option value=3D"11">
November</option>
 <option value=3D"12">
December</option>
</select>
   <select name=3D"entry.1705849412_day" disabled>
<option value=3D"">
Day</option>
<option value=3D"1">
1</option>
 <option value=3D"2">
2</option>
 <option value=3D"3">
3</option>
 <option value=3D"4">
4</option>
 <option value=3D"5" selected>
5</option>
 <option value=3D"6">
6</option>
 <option value=3D"7">
7</option>
 <option value=3D"8">
8</option>
 <option value=3D"9">
9</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value==3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled>
<option value=3D"">
Year</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
 <option value=3D"1898">
1898</option>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
1901</option>
 <option value=3D"1902">
1902</option>
 <option value=3D"1903">
1903</option>
 <option value=3D"1904">
1904</option>
 <option value=3D"1905">
1905</option>
 <option value=3D"1906">
1906</option>
 <option value=3D"1907">
1907</option>
 <option value=3D"1908">
1908</option>
 <option value=3D"1909">
1909</option>
 <option value=3D"1910">
1910</option>
 <option value=3D"1911">
1911</option>
 <option value=3D"1912">
1912</option>
 <option value=3D"1913">
1913</option>
 <option value=3D"1914">
1914</option>
 <option value=3D"1915">
1915</option>
 <option value=3D"1916">
1916</option>
 <option value=3D"1917">
1917</option>
 <option value=3D"1918">
1918</option>
 <option value=3D"1919">
1919</option>
 <option value=3D"1920">
1920</option>
 <option value=3D"1921">
1921</option>
 <option value=3D"1922">
1922</option>
 <option value=3D"1923">
1923</option>
 <option value==3D"1924">
1924</option>
 <option value=3D"1925">
1925</option>
 <option value==3D"1926">
1926</option>
 <option value=3D"1927">
1927</option>
 <option value==3D"1928">
1928</option>
 <option value=3D"1929">
1929</option>
 <option value==3D"1930">
1930</option>
 <option value=3D"1931">
1931</option>
 <option value==3D"1932">
1932</option>
 <option value=3D"1933">
1933</option>
 <option value==3D"1934">
1934</option>
 <option value=3D"1935">
1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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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>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
 <option value=3D"1971">
1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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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>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
 <option value=3D"2019" selected>
2019</option>
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2020</option>
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2021</option>
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2022</option>
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2023</option>
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2024</option>
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2025</option>
 <option value=3D"2026">
2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
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2032</option>
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2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
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2036</option>
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2037</option>
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2038</option>
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2039</option>
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2040</option>
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2041</option>
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2042</option>
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2043</option>
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2044</option>
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2045</option>
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2046</option>
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2047</option>
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2048</option>
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2049</option>
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2050</option>
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2051</option>
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2052</option>
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2053</option>
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2054</option>
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2055</option>
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2056</option>
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2057</option>
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2058</option>
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2059</option>
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2060</option>
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2061</option>
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2062</option>
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2063</option>
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2064</option>
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2065</option>
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2066</option>
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2067</option>
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2068</option>
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2069</option>
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<div dir=3D"auto" style=3D"margin:12px 0;font:inherit">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Hora de la Atenci=C3=B3n<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div>
<div 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">
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<option value=3D"">
Hr</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>
 <option value=3D"06">
06</option>
 <option value=3D"07">
07</option>
 <option value=3D"08">
08</option>
 <option value=3D"09">
09</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
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12</option>
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<option value=3D"">
Min</option>
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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>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value=3D"17">
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>
 <option value=3D"56">
56</option>
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57</option>
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58</option>
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59</option>
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<select name=3D"entry.206244955_ampm" disabled>
<option value=3D"AM">
AM</option>
<option value=3D"PM" selected>
PM</option>
</select>
<div style=3D"height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.1747608258" disabled>
<option value=3D"">
</option>
<option value=3D"0" disabled>
0</option>
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1</option>
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2</option>
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3</option>
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4</option>
</select>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0;overflow-x:auto">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div 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">
<tbody>
<tr>
<td style=3D"text-align:center">
</td>
<td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td style=3D"text-align:center">
</td>
</tr>
<tr>
<td style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div>
</div>
</td>
<td style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div>
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<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"1">
</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled checked value=3D"2">
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</td>
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<div>
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<div>
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<div>
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</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6">
</div>
</td>
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<div>
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<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8">
</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9">
</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"10">
</div>
</td>
<td 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>
<div dir=3D"auto" style=3D"margin:12px 0;overflow-x:auto">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=A1ximo</div>
<div 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">
<tbody>
<tr>
<td style=3D"text-align:center">
</td>
<td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td style=3D"text-align:center">
</td>
</tr>
<tr>
<td style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div>
</div>
</td>
<td style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div>
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</div>
</td>
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</div>
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<div>
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</div>
</td>
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<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"3">
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</div>
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<div>
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</td>
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<div>
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Escala Dolor EVA M=C3=ADnimo</div>
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9</label>
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10</label>
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<div>
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<div>
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"9">
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<div>
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"10">
</div>
</td>
<td style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
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</tbody>
</table>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Anamnesis/Evoluci=C3=B3n<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Paciente de 57 a=C3=B1os con dx de Ca de Ovario estadio IV+ carcinoatosis peritoneal y perifardiofrenica pleural.Derrame pleural ya resuelto.Ascitis controlada  Anasarca controlada dolor en resolucion.En esta visita paciente refier acaba de llegar de realizarse ex=C3=A1menes ordenados por odontologo tratante (hemograma) por probable infecci=C3=B3n odontologica por molar en mal estado. Refiere ademas ya haberse realizado la 1era QMT. Refor hasta momentl haberla bien tolerado.pero se suspenden las secciones por oncologia  hasta completar antibioticoterapia ordenada para la infeccion odontologica. Encuentro paciente sin disnea tolerando decubito y marchando con menos apoyo adicional.</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen F=C3=ADsico<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div 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%">
Presion arterial 1020/76 pulso 77 respiraciones 19 Oximetria 97%. =C3=93rganos de los sentidos normal. Crepitos finos base pulmon izquierdo. Abdomen blando no masas persistalsis presnte ascitis incipiente punto de tension. Extremidades sin edemas.</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div 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%">
Ca de Ovario estadio IV+ carcinoatosis peritoneal y perifardiofrenica pleural. Derrame pleural ya resuelto. Ascitis controlada  Anasarca controlada dolor en resoluci=C3=B3n. Infeccion Odontologica en tto</div>
</div>
</div>
</div>
<br>
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<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
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Plan de Tratamiento e Indicaciones<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
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</div>
</label>
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Continuar tto deontol=C3=B3gico posterior a eso reiniciar qmt con el aval de Oncolog=C3=ADa. Continuar prestaciones para el pr=C3=B3ximo ciclo.</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
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Medicamentos Indicados</div>
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</div>
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Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
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</div>
</label>
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2047</option>
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2048</option>
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2049</option>
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2050</option>
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2051</option>
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2052</option>
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2053</option>
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2054</option>
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2055</option>
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2056</option>
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2057</option>
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2058</option>
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2059</option>
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2060</option>
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2061</option>
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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>
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</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
</label>
<ul style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span style=3D"display:inline-block">
<input type=3D"checkbox" name==3D"entry.503039759" disabled checked value=3D"ENFERMERA">
</span>
<span>
ENFERMERA</span>
</label>
</li>
 <li style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span style=3D"display:inline-block">
<input type=3D"checkbox" name==3D"entry.503039759" disabled value=3D"TENS">
</span>
<span>
TENS</span>
</label>
</li>
 <li style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span style=3D"display:inline-block">
<input type=3D"checkbox" name==3D"entry.503039759" disabled checked value=3D"NUTRICIONISTA">
</span>
<span>
NUTRICIONISTA</span>
</label>
</li>
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<label>
<span style=3D"display:inline-block">
<input type=3D"checkbox" name==3D"entry.503039759" disabled value=3D"KINESIOLOGO">
</span>
<span>
KINESIOLOGO</span>
</label>
</li>
 <li style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span style=3D"display:inline-block">
<input type=3D"checkbox" name==3D"entry.503039759" disabled value=3D"PSICOLOGO">
</span>
<span>
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0;max-width:100%">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img title=3D"" src=3D"https://lh5.googleusercontent.com/Bpur5zPteyG-bXtM-WNRuiLwTi8myvetX7lBkdjzbnQyqUlGcuv84zmWyU3x0Ua2-_WXX9PiJ2cMBOO0zhG2nHX7tXXPHH6_X8UTG8MZzIBwxETkF0a8JyZtuxSL" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</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">
Create your own Google Form</a>
</td>
</tr>
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</table>
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