X-AntiAbuse: Primary Hostname - ns1.hostnow.clX-AntiAbuse: Original Domain - telemed-chile.clX-AntiAbuse: Originator/Caller UID/GID - [47 12] / [47 12]X-AntiAbuse: Sender Address Domain - gmail.comX-Get-Message-Sender-Via: ns1.hostnow.cl: redirect/forwarder owner informeges@telemed-chile.cl ->
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<br>
Enviado desde mi HUAWEI Mate 20 lite<div style="line-height:1.5">
<br>
<br>
-------- Mensaje original --------<br>
Asunto: Registro de Atención Domiciliaria Oncovida<br>
De: Formularios de Google <forms-receipts-noreply@google.com>
<br>
Para: SANDRAMAULENANGEL@GMAIL.COM<br>
CC: <br>
<br>
<blockquote style="margin:0 0 0 0.8ex;border-left:1px #ccc solid;padding-left:1ex">
<blockquote class="quote" style="margin:0 0 0 .8ex;border-left:1px #ccc solid;padding-left:1ex">
<div style="font-family:&#39;roboto&#39; , &#39;helvetica&#39; , &#39;arial&#39; , sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border="0" cellpadding="0" cellspacing="0" style="background-color:rgb( 38 , 4 , 154 )" width="100%">
<tbody>
<tr>
<td style="padding-left:24px">
<img alt="Formularios de Google" height="26px" style="display:inline-block;margin:0;vertical-align:middle" width="143px" src="https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png" />
</td>
</tr>
</tbody>
</table>
<div style="padding:24px;background-color:rgb( 229 , 218 , 254 )">
<div align="center" style="background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align="center" cellpadding="0" cellspacing="0" style="background-color:#fff" width="100%">
<tbody>
<tr>
<td>
</td>
</tr>
<tr>
<td>
<div style="font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por llenar <a href="https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp&#61;mail_form_link">
Registro de Atención Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr>
</tr>
<tr>
<td>
<div style="font-size:13px;line-height:18px;color:#424242">
Estas son tus respuestas:</div>
</td>
</tr>
<tr>
<td>
<div>
<div>
<h1 dir="ltr" style="margin:0.67em 0">
Registro de Atención Domiciliaria Oncovida</h1>

<div style="font:inherit;width:99%;margin:0 0 1em;white-space:pre-wrap;word-wrap:break-word">
Este es el sistema de registro de atenciones domiciliarias de Oncovida.   Debe ser llenado por el prestador individual, y debe realizarse un registro por cada visita domiciliaria.   Si usted no es prestador de Oncovida por favor no llene este formulario.   A continuación indique su correo electrónico.</div>

</div>

<div>
<form action="" method="GET">
<br />

<div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Dirección de correo electrónico
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
SANDRAMAULENANGEL&#64;GMAIL.COM</div>



</div>
</div>
</div>

<div>

<div dir="auto" style="margin:12px 0;max-width:100%">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
</h2>

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

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="margin:2em 0;padding:0.4em;background-color:#eee">
Identificación del Prestador</h2>

<div dir="auto" style="white-space:pre-wrap;word-wrap:break-word">
Aquí debe ingresar sus datos personales</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Primer Nombre y Apellido Paterno
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


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



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
RUT
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
16621429-7</div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Tipo
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
Si asisten más de 1 prestador simultáneamente, cada uno debe hacer un registro independiente</div>


<select name="entry.133691676" disabled="disabled">
<option value="">
</option>
<option value="MEDICO" disabled="disabled">
MEDICO</option>
<option value="ENFERMERA/O" disabled="disabled" selected="selected">
ENFERMERA/O</option>
<option value="TENS" disabled="disabled">
TENS</option>
<option value="KINESIOLOGA/O" disabled="disabled">
KINESIOLOGA/O</option>
<option value="PSICOLOGO" disabled="disabled">
PSICOLOGO</option>
<option value="NUTRICIONISTA" disabled="disabled">
NUTRICIONISTA</option>
</select>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0;max-width:100%">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
</h2>

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

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="margin:2em 0;padding:0.4em;background-color:#eee">
Identificación del Paciente</h2>

<div dir="auto" style="white-space:pre-wrap;word-wrap:break-word">
En esta sección debe ingresar los datos del paciente visitado</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="background-color:#eee;padding:0.4em;margin:2em 0">
Datos Personales del Paciente</h2>

<div style="margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word">
</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Ingrese el Rut del Paciente
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
10553175-3</div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


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



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Previsión
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<select name="entry.545002227" disabled="disabled">
<option value="">
</option>
<option value="BANMEDICA" disabled="disabled" selected="selected">
BANMEDICA</option>
<option value="CAPREDENA" disabled="disabled">
CAPREDENA</option>
<option value="COLMENA" disabled="disabled">
COLMENA</option>
<option value="CONSALUD" disabled="disabled">
CONSALUD</option>
<option value="CRUZ BLANCA" disabled="disabled">
CRUZ BLANCA</option>
<option value="DIPRECA" disabled="disabled">
DIPRECA</option>
<option value="FONASA" disabled="disabled">
FONASA</option>
<option value="FUNDACION" disabled="disabled">
FUNDACION</option>
<option value="ISAPRES DEL COBRE" disabled="disabled">
ISAPRES DEL COBRE</option>
<option value="NUEVA MASVIDA" disabled="disabled">
NUEVA MASVIDA</option>
<option value="VIDATRES" disabled="disabled">
VIDATRES</option>
<option value="PARTICULAR" disabled="disabled">
PARTICULAR</option>
</select>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Ciudad
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


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



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Comuna
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


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



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0;max-width:100%">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
</h2>

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

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="margin:2em 0;padding:0.4em;background-color:#eee">
Registro de la Atención Domiciliaria</h2>

<div dir="auto" style="white-space:pre-wrap;word-wrap:break-word">
En esta sección debe ingresar los datos de la atención domiciliaria</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Tipo de Atención
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>



<ul style="list-style:none;padding:0;margin:0.5em 0 0">
<li style="margin:0;line-height:1.3em;padding-bottom:0.5em">

<label>
<span style="display:inline-block">
<input type="radio" name="entry.1222378237" disabled="disabled" checked="checked" value="Domicilio" />
</span>

Domicilio
</label>
</li>
<li style="margin:0;line-height:1.3em;padding-bottom:0.5em">

<label>
<span style="display:inline-block">
<input type="radio" name="entry.1222378237" disabled="disabled" value="Ambulatorio" />
</span>

Ambulatorio
</label>
</li>
</ul>


</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Fecha de la Atención
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div>
<div style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name="entry.1705849412_month" disabled="disabled">
<option value="">
Mes</option>
<option value="1">
enero</option>
<option value="2">
febrero</option>
<option value="3">
marzo</option>
<option value="4" selected="selected">
abril</option>
<option value="5">
mayo</option>
<option value="6">
junio</option>
<option value="7">
julio</option>
<option value="8">
agosto</option>
<option value="9">
septiembre</option>
<option value="10">
octubre</option>
<option value="11">
noviembre</option>
<option value="12">
diciembre</option>
</select>
   <select name="entry.1705849412_day" disabled="disabled">
<option value="">
Día</option>
<option value="1">
1</option>
<option value="2">
2</option>
<option value="3">
3</option>
<option value="4">
4</option>
<option value="5">
5</option>
<option value="6">
6</option>
<option value="7">
7</option>
<option value="8">
8</option>
<option value="9" selected="selected">
9</option>
<option value="10">
10</option>
<option value="11">
11</option>
<option value="12">
12</option>
<option value="13">
13</option>
<option value="14">
14</option>
<option value="15">
15</option>
<option value="16">
16</option>
<option value="17">
17</option>
<option value="18">
18</option>
<option value="19">
19</option>
<option value="20">
20</option>
<option value="21">
21</option>
<option value="22">
22</option>
<option value="23">
23</option>
<option value="24">
24</option>
<option value="25">
25</option>
<option value="26">
26</option>
<option value="27">
27</option>
<option value="28">
28</option>
<option value="29">
29</option>
<option value="30">
30</option>
<option value="31">
31</option>
</select>
 
<select name="entry.1705849412_year" disabled="disabled">
<option value="">
Año</option>
<option value="1896">
1896</option>
<option value="1897">
1897</option>
<option value="1898">
1898</option>
<option value="1899">
1899</option>
<option value="1900">
1900</option>
<option value="1901">
1901</option>
<option value="1902">
1902</option>
<option value="1903">
1903</option>
<option value="1904">
1904</option>
<option value="1905">
1905</option>
<option value="1906">
1906</option>
<option value="1907">
1907</option>
<option value="1908">
1908</option>
<option value="1909">
1909</option>
<option value="1910">
1910</option>
<option value="1911">
1911</option>
<option value="1912">
1912</option>
<option value="1913">
1913</option>
<option value="1914">
1914</option>
<option value="1915">
1915</option>
<option value="1916">
1916</option>
<option value="1917">
1917</option>
<option value="1918">
1918</option>
<option value="1919">
1919</option>
<option value="1920">
1920</option>
<option value="1921">
1921</option>
<option value="1922">
1922</option>
<option value="1923">
1923</option>
<option value="1924">
1924</option>
<option value="1925">
1925</option>
<option value="1926">
1926</option>
<option value="1927">
1927</option>
<option value="1928">
1928</option>
<option value="1929">
1929</option>
<option value="1930">
1930</option>
<option value="1931">
1931</option>
<option value="1932">
1932</option>
<option value="1933">
1933</option>
<option value="1934">
1934</option>
<option value="1935">
1935</option>
<option value="1936">
1936</option>
<option value="1937">
1937</option>
<option value="1938">
1938</option>
<option value="1939">
1939</option>
<option value="1940">
1940</option>
<option value="1941">
1941</option>
<option value="1942">
1942</option>
<option value="1943">
1943</option>
<option value="1944">
1944</option>
<option value="1945">
1945</option>
<option value="1946">
1946</option>
<option value="1947">
1947</option>
<option value="1948">
1948</option>
<option value="1949">
1949</option>
<option value="1950">
1950</option>
<option value="1951">
1951</option>
<option value="1952">
1952</option>
<option value="1953">
1953</option>
<option value="1954">
1954</option>
<option value="1955">
1955</option>
<option value="1956">
1956</option>
<option value="1957">
1957</option>
<option value="1958">
1958</option>
<option value="1959">
1959</option>
<option value="1960">
1960</option>
<option value="1961">
1961</option>
<option value="1962">
1962</option>
<option value="1963">
1963</option>
<option value="1964">
1964</option>
<option value="1965">
1965</option>
<option value="1966">
1966</option>
<option value="1967">
1967</option>
<option value="1968">
1968</option>
<option value="1969">
1969</option>
<option value="1970">
1970</option>
<option value="1971">
1971</option>
<option value="1972">
1972</option>
<option value="1973">
1973</option>
<option value="1974">
1974</option>
<option value="1975">
1975</option>
<option value="1976">
1976</option>
<option value="1977">
1977</option>
<option value="1978">
1978</option>
<option value="1979">
1979</option>
<option value="1980">
1980</option>
<option value="1981">
1981</option>
<option value="1982">
1982</option>
<option value="1983">
1983</option>
<option value="1984">
1984</option>
<option value="1985">
1985</option>
<option value="1986">
1986</option>
<option value="1987">
1987</option>
<option value="1988">
1988</option>
<option value="1989">
1989</option>
<option value="1990">
1990</option>
<option value="1991">
1991</option>
<option value="1992">
1992</option>
<option value="1993">
1993</option>
<option value="1994">
1994</option>
<option value="1995">
1995</option>
<option value="1996">
1996</option>
<option value="1997">
1997</option>
<option value="1998">
1998</option>
<option value="1999">
1999</option>
<option value="2000">
2000</option>
<option value="2001">
2001</option>
<option value="2002">
2002</option>
<option value="2003">
2003</option>
<option value="2004">
2004</option>
<option value="2005">
2005</option>
<option value="2006">
2006</option>
<option value="2007">
2007</option>
<option value="2008">
2008</option>
<option value="2009">
2009</option>
<option value="2010">
2010</option>
<option value="2011">
2011</option>
<option value="2012">
2012</option>
<option value="2013">
2013</option>
<option value="2014">
2014</option>
<option value="2015">
2015</option>
<option value="2016">
2016</option>
<option value="2017">
2017</option>
<option value="2018">
2018</option>
<option value="2019" selected="selected">
2019</option>
<option value="2020">
2020</option>
<option value="2021">
2021</option>
<option value="2022">
2022</option>
<option value="2023">
2023</option>
<option value="2024">
2024</option>
<option value="2025">
2025</option>
<option value="2026">
2026</option>
<option value="2027">
2027</option>
<option value="2028">
2028</option>
<option value="2029">
2029</option>
<option value="2030">
2030</option>
<option value="2031">
2031</option>
<option value="2032">
2032</option>
<option value="2033">
2033</option>
<option value="2034">
2034</option>
<option value="2035">
2035</option>
<option value="2036">
2036</option>
<option value="2037">
2037</option>
<option value="2038">
2038</option>
<option value="2039">
2039</option>
<option value="2040">
2040</option>
<option value="2041">
2041</option>
<option value="2042">
2042</option>
<option value="2043">
2043</option>
<option value="2044">
2044</option>
<option value="2045">
2045</option>
<option value="2046">
2046</option>
<option value="2047">
2047</option>
<option value="2048">
2048</option>
<option value="2049">
2049</option>
<option value="2050">
2050</option>
<option value="2051">
2051</option>
<option value="2052">
2052</option>
<option value="2053">
2053</option>
<option value="2054">
2054</option>
<option value="2055">
2055</option>
<option value="2056">
2056</option>
<option value="2057">
2057</option>
<option value="2058">
2058</option>
<option value="2059">
2059</option>
<option value="2060">
2060</option>
<option value="2061">
2061</option>
<option value="2062">
2062</option>
<option value="2063">
2063</option>
<option value="2064">
2064</option>
<option value="2065">
2065</option>
<option value="2066">
2066</option>
<option value="2067">
2067</option>
<option value="2068">
2068</option>
<option value="2069">
2069</option>
</select>

</div>

</div>
</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0;font:inherit">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Hora de la Atención
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div>
<div dir="ltr" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
<select name="entry.206244955_hour" disabled="disabled">
<option value="">
h</option>
<option value="00">
00</option>
<option value="01">
01</option>
<option value="02">
02</option>
<option value="03">
03</option>
<option value="04">
04</option>
<option value="05">
05</option>
<option value="06">
06</option>
<option value="07">
07</option>
<option value="08">
08</option>
<option value="09">
09</option>
<option value="10">
10</option>
<option value="11">
11</option>
<option value="12">
12</option>
<option value="13">
13</option>
<option value="14" selected="selected">
14</option>
<option value="15">
15</option>
<option value="16">
16</option>
<option value="17">
17</option>
<option value="18">
18</option>
<option value="19">
19</option>
<option value="20">
20</option>
<option value="21">
21</option>
<option value="22">
22</option>
<option value="23">
23</option>
</select>

.
<select name="entry.206244955_minute" disabled="disabled">
<option value="">
min</option>
<option value="00" selected="selected">
00</option>
<option value="01">
01</option>
<option value="02">
02</option>
<option value="03">
03</option>
<option value="04">
04</option>
<option value="05">
05</option>
<option value="06">
06</option>
<option value="07">
07</option>
<option value="08">
08</option>
<option value="09">
09</option>
<option value="10">
10</option>
<option value="11">
11</option>
<option value="12">
12</option>
<option value="13">
13</option>
<option value="14">
14</option>
<option value="15">
15</option>
<option value="16">
16</option>
<option value="17">
17</option>
<option value="18">
18</option>
<option value="19">
19</option>
<option value="20">
20</option>
<option value="21">
21</option>
<option value="22">
22</option>
<option value="23">
23</option>
<option value="24">
24</option>
<option value="25">
25</option>
<option value="26">
26</option>
<option value="27">
27</option>
<option value="28">
28</option>
<option value="29">
29</option>
<option value="30">
30</option>
<option value="31">
31</option>
<option value="32">
32</option>
<option value="33">
33</option>
<option value="34">
34</option>
<option value="35">
35</option>
<option value="36">
36</option>
<option value="37">
37</option>
<option value="38">
38</option>
<option value="39">
39</option>
<option value="40">
40</option>
<option value="41">
41</option>
<option value="42">
42</option>
<option value="43">
43</option>
<option value="44">
44</option>
<option value="45">
45</option>
<option value="46">
46</option>
<option value="47">
47</option>
<option value="48">
48</option>
<option value="49">
49</option>
<option value="50">
50</option>
<option value="51">
51</option>
<option value="52">
52</option>
<option value="53">
53</option>
<option value="54">
54</option>
<option value="55">
55</option>
<option value="56">
56</option>
<option value="57">
57</option>
<option value="58">
58</option>
<option value="59">
59</option>
</select>



<div style="height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Performance Status ECOG del Paciente
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<select name="entry.1747608258" disabled="disabled">
<option value="">
</option>
<option value="0" disabled="disabled">
0</option>
<option value="1" disabled="disabled">
1</option>
<option value="2" disabled="disabled">
2</option>
<option value="3" disabled="disabled" selected="selected">
3</option>
<option value="4" disabled="disabled">
4</option>
</select>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Escala Dolor EVA Actual
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>



<table border="0" cellpadding="5" cellspacing="0">
<tr>
<td style="text-align:center">
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
0</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
1</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
2</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
3</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
4</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
5</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
6</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
7</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
8</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
9</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
10</label>
</td>
<td style="text-align:center">
</td>
</tr>
<tr>
<td style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em;padding-left:0">
<div>
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="0" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="1" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="2" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" checked="checked" value="3" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="4" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="5" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="6" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="7" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="8" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="9" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="10" />
</div>
</td>
<td style="text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em;padding-right:0">
</td>
</tr>
</table>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Escala Dolor EVA Máximo
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>



<table border="0" cellpadding="5" cellspacing="0">
<tr>
<td style="text-align:center">
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
0</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
1</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
2</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
3</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
4</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
5</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
6</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
7</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
8</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
9</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
10</label>
</td>
<td style="text-align:center">
</td>
</tr>
<tr>
<td style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em;padding-left:0">
<div>
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="0" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="1" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="2" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="3" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="4" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" checked="checked" value="5" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="6" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="7" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="8" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="9" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="10" />
</div>
</td>
<td style="text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em;padding-right:0">
</td>
</tr>
</table>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Escala Dolor EVA Mínimo
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>



<table border="0" cellpadding="5" cellspacing="0">
<tr>
<td style="text-align:center">
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
0</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
1</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
2</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
3</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
4</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
5</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
6</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
7</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
8</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
9</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
10</label>
</td>
<td style="text-align:center">
</td>
</tr>
<tr>
<td style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em;padding-left:0">
<div>
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" checked="checked" value="0" />
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</td>
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<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="1" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="2" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="3" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="4" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="5" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="6" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="7" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="8" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="9" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="10" />
</div>
</td>
<td style="text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em;padding-right:0">
</td>
</tr>
</table>

</div>
</div>
</div>

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 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Anamnesis/Evolución
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
PACIENTE ESTACIONARIO BAJO SU CONDICION CONTINUA CON PERDIDA DE SENSIBILIDAD Y FUERZA EN HEMISFERIO IZQUIERDO, MUY DESGANADO DESMOTIVADO, PREFIERE ESTAR ENCAMADO TODO EL DIA.
REFIERE CEFALEA CONSTANTE EN EL AREA TUMORAL, QUE SEDE CON CEFALMIN ( SEÑORA SILVIA SEÑORA REFIERE QUE SE LLEGA A TOMAR 3 COMPRIMIDOS ).
REPOSO Y SUEÑO IRREGULAR CON QUETIAPINA NO LOGRA DORMIR BIEN
ALIMENTACION BUENA, ESPOSA REFIERE QUE COME MUCHO Y SE LE DA EL GUSTO EN LO QUE QUIERA </div>



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</div>
</div>

<br />
 <div>

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

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Examen Físico
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
PACIENTE CON HEMODINAMIA ESTABLE AFEBRIL NORMOCARDICO 87X NORMOTENSO 130/88, SIN APREMIO VENTILATORIO.
PIEL SANA APESAR DE ESTAR ENCAMADO LOGRA MOVERSE EN BLOQUE O SEMISENTARSE EN CAMA.
ABDI 
EXTREMIDADES CON BUENA PERFUSION DISTAL
SIN EDEMA 
DIURESIS POSITIVAS NORMALES SIN CONTROLAR DE MANERA ADECUADA YA ESFINTER, SE SOLICITA INSTALAR PAÑAL O SABANILLA
DEPOSICIONES DIARIAS</div>



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</div>
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 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Diagnóstico
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


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



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</div>
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 <div>

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

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Plan de Tratamiento e Indicaciones
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
- CAMBIOS DE POSICION
. LUBRICACION DE LA PIEL
. CONTROL EMOCIONAL POR PSICOLOGA SOBRE TODO A NIVEL FAMILIAR
- PACIENTE RECHAZA AYUDA NUTRICIONAL Y PSICOLOGICA
. KINESIOLOGIA SEGUN TOLERANCIA </div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Medicamentos Indicados
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
- TRANSTEC AUMENTO DE 1/2 PARCHE ADA 72 HORAS
- 1 GR DE PARACETAMOL EN CRISIS DE DOLOR DE CABEZA CADA 8 HORAS EN SOS 
- RESCATE DE TRAMADOL GOTAS DE 5 A 10 GOTAS </div>



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<label>
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<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Fecha aproximada del Próximo Control con usted
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div>
<div style="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>
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enero</option>
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febrero</option>
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marzo</option>
<option value="4" selected="selected">
abril</option>
<option value="5">
mayo</option>
<option value="6">
junio</option>
<option value="7">
julio</option>
<option value="8">
agosto</option>
<option value="9">
septiembre</option>
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octubre</option>
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noviembre</option>
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diciembre</option>
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Día</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>
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Año</option>
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1896</option>
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1897</option>
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1898</option>
<option value="1899">
1899</option>
<option value="1900">
1900</option>
<option value="1901">
1901</option>
<option value="1902">
1902</option>
<option value="1903">
1903</option>
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1904</option>
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1905</option>
<option value="1906">
1906</option>
<option value="1907">
1907</option>
<option value="1908">
1908</option>
<option value="1909">
1909</option>
<option value="1910">
1910</option>
<option value="1911">
1911</option>
<option value="1912">
1912</option>
<option value="1913">
1913</option>
<option value="1914">
1914</option>
<option value="1915">
1915</option>
<option value="1916">
1916</option>
<option value="1917">
1917</option>
<option value="1918">
1918</option>
<option value="1919">
1919</option>
<option value="1920">
1920</option>
<option value="1921">
1921</option>
<option value="1922">
1922</option>
<option value="1923">
1923</option>
<option value="1924">
1924</option>
<option value="1925">
1925</option>
<option value="1926">
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>
<option value="1931">
1931</option>
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1932</option>
<option value="1933">
1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
<option value="1967">
1967</option>
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1968</option>
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1969</option>
<option value="1970">
1970</option>
<option value="1971">
1971</option>
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1972</option>
<option value="1973">
1973</option>
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1974</option>
<option value="1975">
1975</option>
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1976</option>
<option value="1977">
1977</option>
<option value="1978">
1978</option>
<option value="1979">
1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
<option value="1984">
1984</option>
<option value="1985">
1985</option>
<option value="1986">
1986</option>
<option value="1987">
1987</option>
<option value="1988">
1988</option>
<option value="1989">
1989</option>
<option value="1990">
1990</option>
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1991</option>
<option value="1992">
1992</option>
<option value="1993">
1993</option>
<option value="1994">
1994</option>
<option value="1995">
1995</option>
<option value="1996">
1996</option>
<option value="1997">
1997</option>
<option value="1998">
1998</option>
<option value="1999">
1999</option>
<option value="2000">
2000</option>
<option value="2001">
2001</option>
<option value="2002">
2002</option>
<option value="2003">
2003</option>
<option value="2004">
2004</option>
<option value="2005">
2005</option>
<option value="2006">
2006</option>
<option value="2007">
2007</option>
<option value="2008">
2008</option>
<option value="2009">
2009</option>
<option value="2010">
2010</option>
<option value="2011">
2011</option>
<option value="2012">
2012</option>
<option value="2013">
2013</option>
<option value="2014">
2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
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2019</option>
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2020</option>
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2021</option>
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2022</option>
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2023</option>
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2024</option>
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2025</option>
<option value="2026">
2026</option>
<option value="2027">
2027</option>
<option value="2028">
2028</option>
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2029</option>
<option value="2030">
2030</option>
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2031</option>
<option value="2032">
2032</option>
<option value="2033">
2033</option>
<option value="2034">
2034</option>
<option value="2035">
2035</option>
<option value="2036">
2036</option>
<option value="2037">
2037</option>
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2038</option>
<option value="2039">
2039</option>
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2040</option>
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2041</option>
<option value="2042">
2042</option>
<option value="2043">
2043</option>
<option value="2044">
2044</option>
<option value="2045">
2045</option>
<option value="2046">
2046</option>
<option value="2047">
2047</option>
<option value="2048">
2048</option>
<option value="2049">
2049</option>
<option value="2050">
2050</option>
<option value="2051">
2051</option>
<option value="2052">
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>
<option value="2058">
2058</option>
<option value="2059">
2059</option>
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2060</option>
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2061</option>
<option value="2062">
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>
<option value="2067">
2067</option>
<option value="2068">
2068</option>
<option value="2069">
2069</option>
</select>

</div>

</div>
</div>
</div>
</div>

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<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Tratamiento Realizado (si corresponde)
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


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



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<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Derivación a otro Prestador Domiciliario
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
Sólo llene esta sección si es médico y solicita la visita de otro prestador del equipo</div>



<ul style="list-style:none;padding:0;margin:0.5em 0 0">
<li style="margin:0;line-height:1.3em;padding-bottom:0.5em">

<label>
<span style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="disabled" value="ENFERMERA" />
</span>

ENFERMERA
</label>
</li>
<li style="margin:0;line-height:1.3em;padding-bottom:0.5em">

<label>
<span style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="disabled" value="TENS" />
</span>

TENS
</label>
</li>
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<label>
<span style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="disabled" value="NUTRICIONISTA" />
</span>

NUTRICIONISTA
</label>
</li>
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<label>
<span style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="disabled" value="KINESIOLOGO" />
</span>

KINESIOLOGO
</label>
</li>
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<label>
<span style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="disabled" value="PSICOLOGO" />
</span>

PSICOLOGO
</label>
</li>
</ul>


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</h2>

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<img src="https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style="width:78px;outline:none" alt="Imagen sin título" />
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<tr>
<td>
<a href="https://docs.google.com/forms?usp&#61;mail_form_link" style="color:#424242;font-size:13px">
Crear tu propio Formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</blockquote>
</div>
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