<div dir=3D"ltr">
Estimadas;<div>
Adjunto registro de atenci=C3=B3n de enfermer=C3=ADa, del paciente Javier Ayancan.</div>
<div>
Saluda Atte;</div>
<div>
<br clear=3D"all">
<div>
<div dir=3D"ltr" class=3D"gmail_signature" data-smartmail=3D"gmail_signature">
<div dir=3D"ltr">
<div style=3D"text-align:center">
<span style=3D"font-size:12.8px">
<b>
<font color=3D"#0b5394">
Romina Soto Q.</font>
</b>
</span>
</div>
<div style=3D"text-align:center">
<b>
<font color=3D"#0b5394">
Enfermera Universitaria</font>
</b>
</div>
<div style=3D"text-align:center">
<b>
<font color=3D"#0b5394">
Contacto: +56954518976</font>
</b>
</div>
</div>
</div>
</div>
<br>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class=3D"gmail_attr">
---------- Forwarded message ---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Formularios de Google</strong>
 <span dir=3D"ltr">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: mar., 9 de abr. de 2019 a la(s) 14:02<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:rominapamela.soto@gmail.com">
rominapamela.soto@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_2501313532148819315ss-form-container">
<div class=3D"m_2501313532148819315ss-form-heading">
<h1 class=3D"m_2501313532148819315ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_2501313532148819315ss-form-desc m_2501313532148819315ss-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_2501313532148819315ss-form">
<form method=3D"GET" id=3D"m_2501313532148819315ss-form" target=3D"_blank">
<br>
<div class=3D"m_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-item-required m_2501313532148819315ss-text" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315emailAddress">
<div class=3D"m_2501313532148819315ss-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_2501313532148819315emailAddress">
</label>
<span class=3D"m_2501313532148819315ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_2501313532148819315ss-q-text m_2501313532148819315ss-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:rominapamela.soto@gmail.com" target=3D"_blank">
rominapamela.soto@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2501313532148819315ss-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_2501313532148819315ss-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_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2501313532148819315ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_2501313532148819315ss-page-description m_2501313532148819315ss-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_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-item-required m_2501313532148819315ss-text" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_579114469">
<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_2501313532148819315itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2501313532148819315ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2501313532148819315ss-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%">
Romina Soto</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-item-required m_2501313532148819315ss-text" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_1276273985">
<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_2501313532148819315itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2501313532148819315ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-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_2501313532148819315ss-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%">
17888342-9</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-item-required m_2501313532148819315ss-select" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_133691676">
<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_2501313532148819315itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2501313532148819315ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-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_2501313532148819315entry_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_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2501313532148819315ss-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_2501313532148819315ss-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_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2501313532148819315ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_2501313532148819315ss-page-description m_2501313532148819315ss-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_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2501313532148819315ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_2501313532148819315ss-section-description m_2501313532148819315ss-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_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-item-required m_2501313532148819315ss-text" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_823811303">
<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_2501313532148819315itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2501313532148819315ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-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_2501313532148819315ss-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%">
13323596-5</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-item-required m_2501313532148819315ss-text" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_1959365839">
<div class=3D"m_2501313532148819315ss-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_2501313532148819315itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2501313532148819315ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2501313532148819315ss-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%">
Javier Ayancan</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-item-required m_2501313532148819315ss-select" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_545002227">
<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_2501313532148819315itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2501313532148819315ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-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_2501313532148819315entry_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_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-item-required m_2501313532148819315ss-text" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_1900161356">
<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_2501313532148819315itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2501313532148819315ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2501313532148819315ss-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_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-item-required m_2501313532148819315ss-text" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_1298871758">
<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_2501313532148819315itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2501313532148819315ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2501313532148819315ss-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_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2501313532148819315ss-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_2501313532148819315ss-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_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2501313532148819315ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_2501313532148819315ss-page-description m_2501313532148819315ss-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_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-item-required m_2501313532148819315ss-radio" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_2073233714">
<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_2501313532148819315itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2501313532148819315ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_2501313532148819315ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_2501313532148819315ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2501313532148819315ss-choice-item-control m_2501313532148819315goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_2501313532148819315group_1222378237_1" class=3D"m_2501313532148819315ss-q-radio">
</span>
<span class=3D"m_2501313532148819315ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_2501313532148819315ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2501313532148819315ss-choice-item-control m_2501313532148819315goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_2501313532148819315group_1222378237_2" class=3D"m_2501313532148819315ss-q-radio">
</span>
<span class=3D"m_2501313532148819315ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-item-required m_2501313532148819315ss-date" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_1705849412">
<div class=3D"m_2501313532148819315ss-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_2501313532148819315itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2501313532148819315ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2501313532148819315ss-q-date">
<div class=3D"m_2501313532148819315ss-datetime-box m_2501313532148819315goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name=3D"entry.1705849412_month" disabled class=3D"m_2501313532148819315ss-month-dropdown" id=3D"m_2501313532148819315entry.1705849412_month">
<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
 <option value=3D"2">
febrero</option>
 <option value=3D"3">
marzo</option>
 <option value=3D"4" selected>
abril</option>
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mayo</option>
 <option value=3D"6">
junio</option>
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julio</option>
 <option value=3D"8">
agosto</option>
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septiembre</option>
 <option value=3D"10">
octubre</option>
 <option value=3D"11">
noviembre</option>
 <option value=3D"12">
diciembre</option>
</select>
   <select name=3D"entry.1705849412_day" disabled class=3D"m_2501313532148819315ss-day-dropdown" id=3D"m_2501313532148819315entry.1705849412_day">
<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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4</option>
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5</option>
 <option value=3D"6">
6</option>
 <option value=3D"7">
7</option>
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8</option>
 <option value=3D"9" selected>
9</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
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>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_2501313532148819315entry.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>
 <option value=3D"1902">
1902</option>
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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>
 <option value==3D"1936">
1936</option>
 <option value=3D"1937">
1937</option>
 <option value==3D"1938">
1938</option>
 <option value=3D"1939">
1939</option>
 <option value==3D"1940">
1940</option>
 <option value=3D"1941">
1941</option>
 <option value==3D"1942">
1942</option>
 <option value=3D"1943">
1943</option>
 <option value==3D"1944">
1944</option>
 <option value=3D"1945">
1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
1948</option>
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1949</option>
 <option value==3D"1950">
1950</option>
 <option value=3D"1951">
1951</option>
 <option value==3D"1952">
1952</option>
 <option value=3D"1953">
1953</option>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
 <option value=3D"1959">
1959</option>
 <option value==3D"1960">
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>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
1976</option>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
 <option value==3D"1980">
1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
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2011</option>
 <option value==3D"2012">
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>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
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2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
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2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-item-required m_2501313532148819315ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_206244955">
<div class=3D"m_2501313532148819315ss-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_2501313532148819315itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2501313532148819315ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2501313532148819315ss-q-time">
<div class=3D"m_2501313532148819315ss-datetime-box m_2501313532148819315goog-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_2501313532148819315entry.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>
 <option value=3D"09" selected>
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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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_2501313532148819315entry.206244955_minute">
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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>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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32</option>
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33</option>
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34</option>
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35</option>
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36</option>
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37</option>
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38</option>
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39</option>
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40</option>
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41</option>
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42</option>
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43</option>
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44</option>
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45</option>
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47</option>
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50</option>
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55</option>
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56</option>
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57</option>
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58</option>
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59</option>
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</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-item-required m_2501313532148819315ss-select" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_1747608258">
<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_2501313532148819315itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2501313532148819315ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
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</div>
</label>
<select name=3D"entry.1747608258" disabled id=3D"m_2501313532148819315entry_1747608258">
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</option>
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0</option>
 <option value=3D"1" disabled selected>
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 class=3D"m_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_1716090865">
<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-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_2501313532148819315entry_1421689035">
<tbody>
<tr>
<td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1421689035_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_2501313532148819315ss-scalerow m_2501313532148819315ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_2501313532148819315aria-todo">
</div>
</td>
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</div>
</td>
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</div>
</td>
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</div>
</td>
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</div>
</td>
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<div class=3D"m_2501313532148819315ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_2501313532148819315group_1421689035_5" class=3D"m_2501313532148819315ss-q-radio">
</div>
</td>
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<div class=3D"m_2501313532148819315ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_2501313532148819315group_1421689035_6" class=3D"m_2501313532148819315ss-q-radio">
</div>
</td>
 <td class=3D"m_2501313532148819315ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2501313532148819315ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_2501313532148819315group_1421689035_7" class=3D"m_2501313532148819315ss-q-radio">
</div>
</td>
 <td class=3D"m_2501313532148819315ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2501313532148819315ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"7" id=3D"m_2501313532148819315group_1421689035_8" class=3D"m_2501313532148819315ss-q-radio">
</div>
</td>
 <td class=3D"m_2501313532148819315ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2501313532148819315ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_2501313532148819315group_1421689035_9" class=3D"m_2501313532148819315ss-q-radio">
</div>
</td>
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<div class=3D"m_2501313532148819315ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_2501313532148819315group_1421689035_10" class=3D"m_2501313532148819315ss-q-radio">
</div>
</td>
 <td class=3D"m_2501313532148819315ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class==3D"m_2501313532148819315ss-scalerow-fieldcell">
<input type=3D"radio" name==3D"entry.1421689035" disabled value=3D"10" id=3D"m_2501313532148819315group_1421689035_11" class=3D"m_2501313532148819315ss-q-radio">
</div>
</td>
<td class=3D"m_2501313532148819315ss-scalerow m_2501313532148819315ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_2064050596">
<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=A1ximo</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-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_2501313532148819315entry_1244707512">
<tbody>
<tr>
<td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2501313532148819315ss-scalenumber" for=3D"m_2501313532148819315group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_2501313532148819315ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_2501313532148819315ss-scalerow m_2501313532148819315ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_2501313532148819315aria-todo">
</div>
</td>
<td class=3D"m_2501313532148819315ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_2501313532148819315ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"0" id=3D"m_2501313532148819315group_1244707512_1" class=3D"m_2501313532148819315ss-q-radio">
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Escala Dolor EVA M=C3=ADnimo</div>
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8</label>
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10</label>
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Se realiza visita en conjunto a Dr. Gonz=C3=A1lez.=20Antecedentes: tumor neuroendocrino de colon derecho operado en 2017, con met=C3=A1stasis hep=C3=A1ticas resecadas, met=C3=A1stasis Oseas tratadas con quimioterapia, radioterapia y zolendronato.=20Sin otro antecedente m=C3=B3rbido conocido.Paciente de 41 a=C3=B1os, con antecedentes descritos. En marzo del presente a=C3=B1o completa 7mo ciclo de QMT con capecitabina + temozolomida. Se realiza PET scan el 01.04.19 que informa progresi=C3=B3n del compromiso ganglionar y hep=C3=A1tico respecto a PET anterior realizado en diciembre del 2018. Tiene ex=C3=A1menes hematol=C3=B3gicos tomados el 01.04.19 (ELP, hemograma, perfil hep=C3=A1tico, creatinina) que no evidencian hallazgos relevantes.=20Nos recibe junto a su madre, con quien vive actualmente. Paciente autovalente, se encuentra en buenas condiciones generales, orientado en tiempo, espacio y persona, ECOG: 1, realiza actividades de la vida diaria sin mayores inconvenientes, sin requerimiento actual de analgesia, sin dolor al momento de la visita. Se mantiene en controles con Dr. Vera, ultimo ayer (08.04.19), con evaluaci=C3=B3n de PET scan, seg=C3=BAn refiere el paciente y por la progresi=C3=B3n de la enfermedad, medico onc=C3=B3logo, le plantea =C3=BAltima alternativa terap=C3=A9utica con lutecio, por lo que actualmente se encuentra a la espera de informe medico para iniciar gestiones de cobertura del medicamento en su Isapre.=20Desde el punto de vista emocional: paciente refiere que hace poco inici=C3==B3 controles con psic=C3=B3loga, a pesar de resultado de ultimo PET; se mantiene con una actitud optimista y positiva, adem=C3=A1s refiere tener buena red de apoyo constituida por la familia principalmente, compa=C3=B1eros de trabajo e iglesia, quienes acompa=C3=B1an el proceso de enfermedad.=20Alimentaci=C3=B3n: paciente posee pauta nutricional personalizada, entregada por medico en Santiago, que se basa principalmente, en mantener buena hidrataci=C3=B3n, abundante consumo de fibra y evitar alimentos altos en grasas y carnes rojas. R=C3=A9gimen bien tolerado.  Mantiene buena adherencia alimentaria.=20Patr=C3=B3n intestinal y vesical: sin alteraciones.Patr=C3=B3n del sue=C3=B1o: sin alteraciones.=20Control de signos vitales: normotenso, euc=C3=A1rdico, saturando dentro de rangos normales.=20P/A 106/75FC 63 x=E2=80=99SaO2 98% FiO2 ambiental </div>
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Piel y mucosas hidratadas, sin  lesiones.=20Hemit=C3=B3rax izquierdo, con aumento de volumen a nivel pectoral, no doloroso a la palpaci=C3=B3n.Abdomen BDI.=20EEII sin edema, movilidad y sensibilidad conservada.=20</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-item-required m_2501313532148819315ss-text" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_1690694733">
<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_2501313532148819315itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2501313532148819315ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2501313532148819315ss-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%">
tumor neuroendocrino de colon derecho operado</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-item-required m_2501313532148819315ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_1255665248">
<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_2501313532148819315itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2501313532148819315ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2501313532148819315ss-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%">
Mantener plan de alimentaci=C3=B3n actualMantener actividades de la vida diaria sin realizar sobre esfuerzosMantener actividades recreativasEducaci=C3=B3n respecto a prevenci=C3=B3n de infecciones respiratorias (estacionarias)Valorar dolor </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_1648939075">
<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2501313532148819315ss-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%">
sin uso de medicamentos actualmente. </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-date" style=3D"margin:12px 0">
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<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2501313532148819315ss-q-date">
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Mes</option>
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febrero</option>
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septiembre</option>
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D=C3=ADa</option>
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1911</option>
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1972</option>
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1979</option>
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1981</option>
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1982</option>
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1984</option>
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2010</option>
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2011</option>
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2012</option>
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2017</option>
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2018</option>
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2020</option>
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2021</option>
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2022</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>
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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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<br>
 <div class=3D"m_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-text" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_74766472">
<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2501313532148819315ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2501313532148819315ss-form-question m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2501313532148819315ss-q-item-label" for=3D"m_2501313532148819315entry_1219705969">
<div class=3D"m_2501313532148819315ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_2501313532148819315ss-q-help m_2501313532148819315ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
</label>
<ul class=3D"m_2501313532148819315ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
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<label>
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</span>
<span class=3D"m_2501313532148819315ss-choice-label">
ENFERMERA</span>
</label>
</li>
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<label>
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<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_2501313532148819315group_503039759_2" class=3D"m_2501313532148819315ss-q-checkbox">
</span>
<span class=3D"m_2501313532148819315ss-choice-label">
TENS</span>
</label>
</li>
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<label>
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<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id==3D"m_2501313532148819315group_503039759_3" class=3D"m_2501313532148819315ss-q-checkbox">
</span>
<span class=3D"m_2501313532148819315ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
 <li class=3D"m_2501313532148819315ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2501313532148819315ss-choice-item-control m_2501313532148819315goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"KINESIOLOGO" id=3D"m_2501313532148819315group_503039759_4" class=3D"m_2501313532148819315ss-q-checkbox">
</span>
<span class=3D"m_2501313532148819315ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
 <li class=3D"m_2501313532148819315ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_2501313532148819315ss-choice-item-control m_2501313532148819315goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"PSICOLOGO" id=3D"m_2501313532148819315group_503039759_5" class=3D"m_2501313532148819315ss-q-checkbox">
</span>
<span class=3D"m_2501313532148819315ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_2501313532148819315errorbox-good">
<div dir=3D"auto" class=3D"m_2501313532148819315ss-item m_2501313532148819315ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_2501313532148819315ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2501313532148819315ss-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_2501313532148819315ss-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>
</div>
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