<div>
<br>
</div>
<div>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class==3D"gmail_attr">
----------=C2=A0Mensaje reenviado=C2=A0---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Formularios de Google</strong>
 <span dir=3D"ltr">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Fecha: El dom, 7 de abr. de 2019 a las 20:09<br>
Asunto: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
Para:  &lt;<a href=3D"mailto:carolinaandrea.vsanchez@gmail.com">
carolinaandrea.vsanchez@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 llenar <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">
Estas son tus respuestas:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_-6683499669359354399ss-form-container">
<div class=3D"m_-6683499669359354399ss-form-heading">
<h1 class=3D"m_-6683499669359354399ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_-6683499669359354399ss-form-desc m_-6683499669359354399ss-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_-6683499669359354399ss-form">
<form method=3D"GET" id=3D"m_-6683499669359354399ss-form" target=3D"_blank">
<br>
<div class=3D"m_-6683499669359354399ss-form-question m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-item-required m_-6683499669359354399ss-text" style=3D"margin:12px 0">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-6683499669359354399ss-q-item-label" for=3D"m_-6683499669359354399emailAddress">
<div class=3D"m_-6683499669359354399ss-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_-6683499669359354399emailAddress">
</label>
<span class=3D"m_-6683499669359354399ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_-6683499669359354399ss-q-text m_-6683499669359354399ss-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:carolinaandrea.vsanchez@gmail.com" target=3D"_blank">
carolinaandrea.vsanchez@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-6683499669359354399ss-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_-6683499669359354399ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-6683499669359354399ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_-6683499669359354399ss-page-description m_-6683499669359354399ss-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_-6683499669359354399ss-form-question m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-item-required m_-6683499669359354399ss-text" style=3D"margin:12px 0">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-6683499669359354399ss-q-item-label" for=3D"m_-6683499669359354399entry_579114469">
<div class=3D"m_-6683499669359354399ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_-6683499669359354399itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-6683499669359354399ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-6683499669359354399ss-q-help m_-6683499669359354399ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-6683499669359354399ss-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%">
Carolina vargas</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-6683499669359354399ss-form-question m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-item-required m_-6683499669359354399ss-text" style=3D"margin:12px 0">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-6683499669359354399ss-q-item-label" for=3D"m_-6683499669359354399entry_1276273985">
<div class=3D"m_-6683499669359354399ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_-6683499669359354399itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-6683499669359354399ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-6683499669359354399ss-q-help m_-6683499669359354399ss-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_-6683499669359354399ss-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%">
17528747-7</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-6683499669359354399ss-form-question m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-item-required m_-6683499669359354399ss-select" style=3D"margin:12px 0">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-6683499669359354399ss-q-item-label" for=3D"m_-6683499669359354399entry_133691676">
<div class=3D"m_-6683499669359354399ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_-6683499669359354399itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-6683499669359354399ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-6683499669359354399ss-q-help m_-6683499669359354399ss-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_-6683499669359354399entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled selected>
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_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-6683499669359354399ss-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_-6683499669359354399ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-6683499669359354399ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_-6683499669359354399ss-page-description m_-6683499669359354399ss-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_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-6683499669359354399ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_-6683499669359354399ss-section-description m_-6683499669359354399ss-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_-6683499669359354399ss-form-question m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-item-required m_-6683499669359354399ss-text" style=3D"margin:12px 0">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-6683499669359354399ss-q-item-label" for=3D"m_-6683499669359354399entry_823811303">
<div class=3D"m_-6683499669359354399ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_-6683499669359354399itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-6683499669359354399ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-6683499669359354399ss-q-help m_-6683499669359354399ss-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_-6683499669359354399ss-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%">
8982264-5</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-6683499669359354399ss-form-question m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-item-required m_-6683499669359354399ss-text" style=3D"margin:12px 0">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-6683499669359354399ss-q-item-label" for=3D"m_-6683499669359354399entry_1959365839">
<div class=3D"m_-6683499669359354399ss-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_-6683499669359354399itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-6683499669359354399ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-6683499669359354399ss-q-help m_-6683499669359354399ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-6683499669359354399ss-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%">
Humberto oyarzun</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-6683499669359354399ss-form-question m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-item-required m_-6683499669359354399ss-select" style=3D"margin:12px 0">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-6683499669359354399ss-q-item-label" for=3D"m_-6683499669359354399entry_545002227">
<div class=3D"m_-6683499669359354399ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_-6683499669359354399itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-6683499669359354399ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-6683499669359354399ss-q-help m_-6683499669359354399ss-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_-6683499669359354399entry_545002227">
<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 class=3D"m_-6683499669359354399ss-form-question m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-item-required m_-6683499669359354399ss-text" style=3D"margin:12px 0">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-6683499669359354399ss-q-item-label" for=3D"m_-6683499669359354399entry_1900161356">
<div class=3D"m_-6683499669359354399ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_-6683499669359354399itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-6683499669359354399ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-6683499669359354399ss-q-help m_-6683499669359354399ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-6683499669359354399ss-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%">
Puerto montt</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-6683499669359354399ss-form-question m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-item-required m_-6683499669359354399ss-text" style=3D"margin:12px 0">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-6683499669359354399ss-q-item-label" for=3D"m_-6683499669359354399entry_1298871758">
<div class=3D"m_-6683499669359354399ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_-6683499669359354399itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-6683499669359354399ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-6683499669359354399ss-q-help m_-6683499669359354399ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-6683499669359354399ss-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%">
Puerto montt</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-6683499669359354399ss-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_-6683499669359354399ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-6683499669359354399ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_-6683499669359354399ss-page-description m_-6683499669359354399ss-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_-6683499669359354399ss-form-question m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-item-required m_-6683499669359354399ss-radio" style=3D"margin:12px 0">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-6683499669359354399ss-q-item-label" for=3D"m_-6683499669359354399entry_2073233714">
<div class=3D"m_-6683499669359354399ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_-6683499669359354399itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-6683499669359354399ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-6683499669359354399ss-q-help m_-6683499669359354399ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_-6683499669359354399ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-6683499669359354399ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-6683499669359354399ss-choice-item-control m_-6683499669359354399goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_-6683499669359354399group_1222378237_1" class=3D"m_-6683499669359354399ss-q-radio">
</span>
<span class=3D"m_-6683499669359354399ss-choice-label">
Domicilio</span>
</label>
</li>
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<label>
<span class=3D"m_-6683499669359354399ss-choice-item-control m_-6683499669359354399goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_-6683499669359354399group_1222378237_2" class=3D"m_-6683499669359354399ss-q-radio">
</span>
<span class=3D"m_-6683499669359354399ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-6683499669359354399ss-form-question m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-item-required m_-6683499669359354399ss-date" style=3D"margin:12px 0">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-6683499669359354399ss-q-item-label" for=3D"m_-6683499669359354399entry_1705849412">
<div class=3D"m_-6683499669359354399ss-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_-6683499669359354399itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-6683499669359354399ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-6683499669359354399ss-q-help m_-6683499669359354399ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-6683499669359354399ss-q-date">
<div class=3D"m_-6683499669359354399ss-datetime-box m_-6683499669359354399goog-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">
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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>
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diciembre</option>
</select>
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<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>
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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>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_-6683499669359354399entry.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>
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1905</option>
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1906</option>
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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>
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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>
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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>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
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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>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
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1968</option>
 <option value=3D"1969">
1969</option>
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1970</option>
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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>
 <option value==3D"2018">
2018</option>
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2019</option>
 <option value=3D"2020">
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>
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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>
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2034</option>
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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>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
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>
 <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>
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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>
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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>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-6683499669359354399ss-form-question m_-6683499669359354399errorbox-good">
<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-item-required m_-6683499669359354399ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-6683499669359354399ss-q-item-label" for=3D"m_-6683499669359354399entry_206244955">
<div class=3D"m_-6683499669359354399ss-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_-6683499669359354399itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-6683499669359354399ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-6683499669359354399ss-q-help m_-6683499669359354399ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-6683499669359354399ss-q-time">
<div class=3D"m_-6683499669359354399ss-datetime-box m_-6683499669359354399goog-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_-6683499669359354399entry.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>
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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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.<select name=3D"entry.206244955_minute" disabled id=3D"m_-6683499669359354399entry.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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14</option>
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19</option>
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22</option>
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25</option>
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26</option>
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27</option>
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29</option>
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31</option>
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33</option>
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34</option>
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39</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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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 class=3D"m_-6683499669359354399ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_-6683499669359354399itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-6683499669359354399ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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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>
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</div>
</div>
<br>
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<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-6683499669359354399ss-q-item-label" for=3D"m_-6683499669359354399entry_1716090865">
<div class=3D"m_-6683499669359354399ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_-6683499669359354399ss-q-help m_-6683499669359354399ss-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_-6683499669359354399entry_1421689035">
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</td>
<td class=3D"m_-6683499669359354399ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
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<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
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<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1421689035_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
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<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
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<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
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<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
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<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1421689035_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
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<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-6683499669359354399ss-scalenumbers" style=3D"text-align:center">
</td>
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</div>
</div>
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<div dir=3D"auto" class=3D"m_-6683499669359354399ss-item m_-6683499669359354399ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-6683499669359354399ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-6683499669359354399ss-q-item-label" for=3D"m_-6683499669359354399entry_2064050596">
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Escala Dolor EVA M=C3=A1ximo</div>
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</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_-6683499669359354399entry_1244707512">
<tbody>
<tr>
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</td>
<td class=3D"m_-6683499669359354399ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-6683499669359354399ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-6683499669359354399ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1244707512_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-6683499669359354399ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-6683499669359354399ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-6683499669359354399ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1244707512_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-6683499669359354399ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-6683499669359354399ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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<label class=3D"m_-6683499669359354399ss-scalenumber" for=3D"m_-6683499669359354399group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-6683499669359354399ss-scalenumbers" style=3D"text-align:center">
</td>
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<tr>
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<div class==3D"m_-6683499669359354399aria-todo">
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</td>
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Escala Dolor EVA M=C3=ADnimo</div>
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0</label>
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1</label>
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2</label>
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3</label>
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4</label>
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5</label>
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6</label>
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7</label>
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8</label>
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9</label>
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10</label>
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</td>
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Anamnesis/Evoluci=C3=B3n<label for=3D"m_-6683499669359354399itemView.getDomIdToLabel()">
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<span class=3D"m_-6683499669359354399ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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</div>
</label>
<div class=3D"m_-6683499669359354399ss-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%">
Usuario con cancer renal, estubo en tratamiento quirurgico: monoreno, con ciclos de quimioterapia, radioterapia. Metastasis osea, fractura patologica en miembro superior derecho operado.Con antecedentes de HTA, DM2 sin tratamiento, falla renal rechazo de dialisis.ECOG 3Medicamentos: metoclopramida  10 mg cada 8 hrs, ondasentron 4 mg cada 8 hrs, domperidona 10 mg cada 8 hrs, clonazepam 2 mg 1/2 comprimido en la noche, transtec 35 mcg/h 3 parches cada 7 dias. (Tratamiento verbalizado por la esposa)=20Usuario en regulares condiciones generales, orientado en tiempo y espacio al momento de la visita, familiares refieren que algunos lapsos se desorienta. Dolor generalizado 2/10 EVA utilizando actualmente 1 parcha de transtec, esposa refiere que se habia mantenido sin dolor por eso bajo la dosis de los parches transdermicos. Se mantiene gran parte en cama, se moviliza en cama, se levanta con ayuda para ir al ba=C3=B1o.=20Alimentacion: inapetente, nauseas (+) gran parte del dia, no quiere tomar sus medicamentos indicados. Liquidos a tolerancia, alimentaci=C3=B3n asistida. Vomitos (-).Eliminacion: En ba=C3=B1o con ayuda, deposiciones (+) debitos urinarios bajos.Patron del sue=C3=B1o: logra conciliar y mantener el sue=C3=B1o durante la noche, somnoliento durante el dia.Movilidad: escasa, se cambia de posicion en cama solo pero con gran dificultad, ayuda para realizar gran parte de las actividades de aseo y confort.</div>
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Examen F=C3=ADsico<label for=3D"m_-6683499669359354399itemView.getDomIdToLabel()">
</label>
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*</span>
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Piel y mucosas secas, pulsos (+), llene capilar normal.Abdomen blando depresible sin dolor a la palpacion.Descata edema en extremidades inferiores (+++) y en extremidad superior derecha (++)Presion arterial: 121/60=20Pulso: 63x=E2=80=99</div>
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Diagn=C3=B3stico<label for=3D"m_-6683499669359354399itemView.getDomIdToLabel()">
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Ca renal</div>
</div>
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Mantener analgesia segun indicacion medicaValorar las caracteristicas del dolorAlimentacion segun toleranciaAumento de liquidos a tolerancia de preferencia friosCambios de posicion en cama para evitar UPPExtremidades inferiores en alto 30=E2=80=A2Pendiente examenes de sangre indicados por m=C3=A9dico=20Valorar debitos urinariosProxima visita segun indicacion medica</div>
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2034</option>
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2037</option>
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2040</option>
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2044</option>
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2045</option>
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2050</option>
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2051</option>
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2055</option>
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2056</option>
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2060</option>
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2064</option>
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2065</option>
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2066</option>
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Derivaci=C3=B3n a otro Prestador Domiciliario</div>
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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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</h2>
<div style=3D"text-align:right">
<img class=3D"m_-6683499669359354399ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</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">
Crear tu propio Formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
-- <br>
<div dir=3D"ltr" class=3D"gmail_signature" data-smartmail=3D"gmail_signature">
Carolina Vargas </div>
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