<div dir=3D"ltr">
<br>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class==3D"gmail_attr">
---------- Forwarded message ---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Google Forms</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: dom., 21 abr. 2019 a las 20:52<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:claudio.ravi94@gmail.com">
claudio.ravi94@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"Google Forms" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style==3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Thanks for filling out <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target=3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Here&#39;s what we got from you:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_-3937552209261337507ss-form-container">
<div class=3D"m_-3937552209261337507ss-form-heading">
<h1 class=3D"m_-3937552209261337507ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_-3937552209261337507ss-form-desc m_-3937552209261337507ss-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_-3937552209261337507ss-form">
<form method=3D"GET" id=3D"m_-3937552209261337507ss-form" target=3D"_blank">
<br>
<div class=3D"m_-3937552209261337507ss-form-question m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-item-required m_-3937552209261337507ss-text" style=3D"margin:12px 0">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-3937552209261337507ss-q-item-label" for=3D"m_-3937552209261337507emailAddress">
<div class=3D"m_-3937552209261337507ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Email address<label for=3D"m_-3937552209261337507emailAddress">
</label>
<span class=3D"m_-3937552209261337507ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_-3937552209261337507ss-q-text m_-3937552209261337507ss-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:claudio.ravi94@gmail.com" target=3D"_blank">
claudio.ravi94@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-3937552209261337507ss-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_-3937552209261337507ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-3937552209261337507ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_-3937552209261337507ss-page-description m_-3937552209261337507ss-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_-3937552209261337507ss-form-question m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-item-required m_-3937552209261337507ss-text" style=3D"margin:12px 0">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-3937552209261337507ss-q-item-label" for=3D"m_-3937552209261337507entry_579114469">
<div class=3D"m_-3937552209261337507ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_-3937552209261337507itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-3937552209261337507ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-3937552209261337507ss-q-help m_-3937552209261337507ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-3937552209261337507ss-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%">
Claudio Ram=C3=ADrez</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-3937552209261337507ss-form-question m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-item-required m_-3937552209261337507ss-text" style=3D"margin:12px 0">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-3937552209261337507ss-q-item-label" for=3D"m_-3937552209261337507entry_1276273985">
<div class=3D"m_-3937552209261337507ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_-3937552209261337507itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-3937552209261337507ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-3937552209261337507ss-q-help m_-3937552209261337507ss-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_-3937552209261337507ss-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%">
18502492-k</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-3937552209261337507ss-form-question m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-item-required m_-3937552209261337507ss-select" style=3D"margin:12px 0">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-3937552209261337507ss-q-item-label" for=3D"m_-3937552209261337507entry_133691676">
<div class=3D"m_-3937552209261337507ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_-3937552209261337507itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-3937552209261337507ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-3937552209261337507ss-q-help m_-3937552209261337507ss-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_-3937552209261337507entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled selected>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-3937552209261337507ss-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_-3937552209261337507ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-3937552209261337507ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_-3937552209261337507ss-page-description m_-3937552209261337507ss-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_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-3937552209261337507ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_-3937552209261337507ss-section-description m_-3937552209261337507ss-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_-3937552209261337507ss-form-question m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-item-required m_-3937552209261337507ss-text" style=3D"margin:12px 0">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-3937552209261337507ss-q-item-label" for=3D"m_-3937552209261337507entry_823811303">
<div class=3D"m_-3937552209261337507ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_-3937552209261337507itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-3937552209261337507ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-3937552209261337507ss-q-help m_-3937552209261337507ss-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_-3937552209261337507ss-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%">
5794927-9</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-3937552209261337507ss-form-question m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-item-required m_-3937552209261337507ss-text" style=3D"margin:12px 0">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-3937552209261337507ss-q-item-label" for=3D"m_-3937552209261337507entry_1959365839">
<div class=3D"m_-3937552209261337507ss-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_-3937552209261337507itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-3937552209261337507ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-3937552209261337507ss-q-help m_-3937552209261337507ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-3937552209261337507ss-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%">
Luis Diaz</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-3937552209261337507ss-form-question m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-item-required m_-3937552209261337507ss-select" style=3D"margin:12px 0">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-3937552209261337507ss-q-item-label" for=3D"m_-3937552209261337507entry_545002227">
<div class=3D"m_-3937552209261337507ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_-3937552209261337507itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-3937552209261337507ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-3937552209261337507ss-q-help m_-3937552209261337507ss-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_-3937552209261337507entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
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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>
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DIPRECA</option>
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FONASA</option>
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FUNDACION</option>
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ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled>
NUEVA MASVIDA</option>
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VIDATRES</option>
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PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-3937552209261337507ss-form-question m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-item-required m_-3937552209261337507ss-text" style=3D"margin:12px 0">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-3937552209261337507ss-q-item-label" for=3D"m_-3937552209261337507entry_1900161356">
<div class=3D"m_-3937552209261337507ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_-3937552209261337507itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-3937552209261337507ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-3937552209261337507ss-q-help m_-3937552209261337507ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-3937552209261337507ss-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%">
Antofagasta</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-3937552209261337507ss-form-question m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-item-required m_-3937552209261337507ss-text" style=3D"margin:12px 0">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-3937552209261337507ss-q-item-label" for=3D"m_-3937552209261337507entry_1298871758">
<div class=3D"m_-3937552209261337507ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_-3937552209261337507itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-3937552209261337507ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-3937552209261337507ss-q-help m_-3937552209261337507ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-3937552209261337507ss-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%">
Antofagasta</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-3937552209261337507ss-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_-3937552209261337507ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-3937552209261337507ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_-3937552209261337507ss-page-description m_-3937552209261337507ss-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_-3937552209261337507ss-form-question m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-item-required m_-3937552209261337507ss-radio" style=3D"margin:12px 0">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-3937552209261337507ss-q-item-label" for=3D"m_-3937552209261337507entry_2073233714">
<div class=3D"m_-3937552209261337507ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_-3937552209261337507itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-3937552209261337507ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-3937552209261337507ss-q-help m_-3937552209261337507ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_-3937552209261337507ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-3937552209261337507ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-3937552209261337507ss-choice-item-control m_-3937552209261337507goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_-3937552209261337507group_1222378237_1" class=3D"m_-3937552209261337507ss-q-radio">
</span>
<span class=3D"m_-3937552209261337507ss-choice-label">
Domicilio</span>
</label>
</li>
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<label>
<span class=3D"m_-3937552209261337507ss-choice-item-control m_-3937552209261337507goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_-3937552209261337507group_1222378237_2" class=3D"m_-3937552209261337507ss-q-radio">
</span>
<span class=3D"m_-3937552209261337507ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-3937552209261337507ss-form-question m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-item-required m_-3937552209261337507ss-date" style=3D"margin:12px 0">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-3937552209261337507ss-q-item-label" for=3D"m_-3937552209261337507entry_1705849412">
<div class=3D"m_-3937552209261337507ss-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_-3937552209261337507itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-3937552209261337507ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-3937552209261337507ss-q-help m_-3937552209261337507ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-3937552209261337507ss-q-date">
<div class=3D"m_-3937552209261337507ss-datetime-box m_-3937552209261337507goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
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<option value==3D"">
Month</option>
<option value=3D"1">
January</option>
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February</option>
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March</option>
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April</option>
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May</option>
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June</option>
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July</option>
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August</option>
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September</option>
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October</option>
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November</option>
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December</option>
</select>
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<option value=3D"">
Day</option>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_-3937552209261337507entry.1705849412_year">
<option value=3D"">
Year</option>
<option value=3D"1896">
1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
 <option value=3D"1907">
1907</option>
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1908</option>
 <option value=3D"1909">
1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
 <option value==3D"1938">
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>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
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>
 <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>
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1959</option>
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1960</option>
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1961</option>
 <option value==3D"1962">
1962</option>
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1963</option>
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1964</option>
 <option value=3D"1965">
1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
 <option value==3D"1972">
1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
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1980</option>
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1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
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1984</option>
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1985</option>
 <option value==3D"1986">
1986</option>
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1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
 <option value==3D"1996">
1996</option>
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1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
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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>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
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2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
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2029</option>
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2030</option>
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2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
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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>
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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>
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2053</option>
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2054</option>
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2055</option>
 <option value==3D"2056">
2056</option>
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2057</option>
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2058</option>
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2059</option>
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2060</option>
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2061</option>
 <option value==3D"2062">
2062</option>
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2063</option>
 <option value==3D"2064">
2064</option>
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2065</option>
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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_-3937552209261337507ss-form-question m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-item-required m_-3937552209261337507ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-3937552209261337507ss-q-item-label" for=3D"m_-3937552209261337507entry_206244955">
<div class=3D"m_-3937552209261337507ss-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_-3937552209261337507itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-3937552209261337507ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-3937552209261337507ss-q-help m_-3937552209261337507ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-3937552209261337507ss-q-time">
<div class=3D"m_-3937552209261337507ss-datetime-box m_-3937552209261337507goog-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_-3937552209261337507entry.206244955_hour">
<option value=3D"">
Hr</option>
<option value=3D"01">
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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:<select name=3D"entry.206244955_minute" disabled id=3D"m_-3937552209261337507entry.206244955_minute">
<option value=3D"">
Min</option>
<option value=3D"00" selected>
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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21</option>
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22</option>
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23</option>
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24</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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32</option>
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33</option>
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34</option>
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35</option>
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36</option>
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37</option>
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38</option>
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39</option>
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40</option>
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41</option>
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42</option>
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43</option>
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44</option>
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45</option>
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46</option>
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47</option>
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48</option>
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49</option>
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50</option>
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51</option>
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52</option>
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53</option>
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54</option>
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55</option>
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56</option>
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57</option>
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58</option>
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59</option>
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<select name=3D"entry.206244955_ampm" disabled>
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AM</option>
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PM</option>
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</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-3937552209261337507ss-form-question m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-item-required m_-3937552209261337507ss-select" style=3D"margin:12px 0">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
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<div class=3D"m_-3937552209261337507ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_-3937552209261337507itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-3937552209261337507ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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</div>
</label>
<select name=3D"entry.1747608258" disabled id=3D"m_-3937552209261337507entry_1747608258">
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</option>
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0</option>
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1</option>
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2</option>
 <option value=3D"3" disabled selected>
3</option>
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4</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-3937552209261337507ss-form-question m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-3937552209261337507ss-q-item-label" for=3D"m_-3937552209261337507entry_1716090865">
<div class=3D"m_-3937552209261337507ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_-3937552209261337507ss-q-help m_-3937552209261337507ss-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_-3937552209261337507entry_1421689035">
<tbody>
<tr>
<td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1421689035_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1421689035_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-3937552209261337507ss-scalerow m_-3937552209261337507ss-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_-3937552209261337507aria-todo">
</div>
</td>
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</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"1" id=3D"m_-3937552209261337507group_1421689035_2" class=3D"m_-3937552209261337507ss-q-radio">
</div>
</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"2" id=3D"m_-3937552209261337507group_1421689035_3" class==3D"m_-3937552209261337507ss-q-radio">
</div>
</td>
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</div>
</td>
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<div class=3D"m_-3937552209261337507ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_-3937552209261337507group_1421689035_5" class=3D"m_-3937552209261337507ss-q-radio">
</div>
</td>
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<div class=3D"m_-3937552209261337507ss-scalerow-fieldcell">
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</td>
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<div class=3D"m_-3937552209261337507ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_-3937552209261337507group_1421689035_7" class=3D"m_-3937552209261337507ss-q-radio">
</div>
</td>
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</div>
</td>
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</div>
</td>
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<div class=3D"m_-3937552209261337507ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_-3937552209261337507group_1421689035_10" class=3D"m_-3937552209261337507ss-q-radio">
</div>
</td>
 <td class=3D"m_-3937552209261337507ss-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_-3937552209261337507ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"10" id=3D"m_-3937552209261337507group_1421689035_11" class=3D"m_-3937552209261337507ss-q-radio">
</div>
</td>
<td class=3D"m_-3937552209261337507ss-scalerow m_-3937552209261337507ss-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_-3937552209261337507ss-form-question m_-3937552209261337507errorbox-good">
<div dir=3D"auto" class=3D"m_-3937552209261337507ss-item m_-3937552209261337507ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-3937552209261337507ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-3937552209261337507ss-q-item-label" for=3D"m_-3937552209261337507entry_2064050596">
<div class=3D"m_-3937552209261337507ss-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_-3937552209261337507ss-q-help m_-3937552209261337507ss-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_-3937552209261337507entry_1244707512">
<tbody>
<tr>
<td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1244707512_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1244707512_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-3937552209261337507ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-3937552209261337507ss-scalerow m_-3937552209261337507ss-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_-3937552209261337507aria-todo">
</div>
</td>
<td class=3D"m_-3937552209261337507ss-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_-3937552209261337507ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"0" id=3D"m_-3937552209261337507group_1244707512_1" class=3D"m_-3937552209261337507ss-q-radio">
</div>
</td>
 <td class=3D"m_-3937552209261337507ss-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_-3937552209261337507ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"1" id=3D"m_-3937552209261337507group_1244707512_2" class=3D"m_-3937552209261337507ss-q-radio">
</div>
</td>
 <td class=3D"m_-3937552209261337507ss-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_-3937552209261337507ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"2" id=3D"m_-3937552209261337507group_1244707512_3" class==3D"m_-3937552209261337507ss-q-radio">
</div>
</td>
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Escala Dolor EVA M=C3=ADnimo</div>
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0</label>
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<label class=3D"m_-3937552209261337507ss-scalenumber" for=3D"m_-3937552209261337507group_853118630_2" style=3D"display:block;padding:0.5em 0 .5em">
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2</label>
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3</label>
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4</label>
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5</label>
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6</label>
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7</label>
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8</label>
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9</label>
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10</label>
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Anamnesis/Evoluci=C3=B3n<label for=3D"m_-3937552209261337507itemView.getDomIdToLabel()">
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*</span>
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Luis Diaz, Paciente de 73 a=C3=B1os.Actualmente Don Luis se encuentra con una met=C3=A1stasis Ganglionar la cual se manifiesta de forma f=C3=ADsica en su zona genital. Afortunadamente hasta ahora no siente dolor pero por motivos l=C3=B3gicos el gran volumen de su zona genital le incomoda en labores personales como el aseo o movilizarse de un lugar a otro, aunque de igual forma lo hace.Don Luis estuvo recientemente hospitalizado, fue un proceso dif=C3=ADcil ya que jam=C3=A1s en su vida hab=C3=ADa estado en esta situaci=C3=B3n, por lo que el nerviosismo y la irritabilidad no se hicieron esperar. Habiendo superado este episodio y estando actualmente en su hogar bajo los cuidados de su hija menor, se le puede apreciar como una persona con un sentido del humor muy peculiar, lo cual le ha ayudado a sobrellevar este dif=C3=ADcil proceso.Manifiesta estar tranquilo y que su familia a pesar de haber sufrido un golpe fuerte se encuentran super pendientes de =C3=A9l. Si fuera por =C3=A9l se ir=C3=ADa a trabajar por que no concibe estar todo el d=C3=ADa pasivo en su casa, sin embargo por razones l=C3=B3gicas no lo puede hacer.Esta muy pr=C3=B3ximo a someterse a quimio terapia, no obstante esto no es algo que literalmente le quite el sue=C3=B1o, se encuentra tranquilo y conf=C3=ADa en que las cosas saldr=C3=A1n bien.</div>
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Examen F=C3=ADsico<label for=3D"m_-3937552209261337507itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-3937552209261337507ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
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</div>
</label>
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Dentro de lo esperable, la =C3=BAnica complicaci=C3=B3n es la inflamaci=C3=B3n en su zona genital, sin embargo y afortunadamente puede realizar por cuenta propia labores b=C3=A1sicas como su higiene y cosas de esa =C3=ADndole.</div>
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Diagn=C3=B3stico<label for=3D"m_-3937552209261337507itemView.getDomIdToLabel()">
</label>
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*</span>
</div>
<div class=3D"m_-3937552209261337507ss-q-help m_-3937552209261337507ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
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C=C3=A1ncer en estudio. Actualmente se ha manifestado con metast=C3=A1sis ganglionar en la zona genital.</div>
</div>
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Plan de Tratamiento e Indicaciones<label for=3D"m_-3937552209261337507itemView.getDomIdToLabel()">
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<span class=3D"m_-3937552209261337507ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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Trabajar y potenciar la esfera afectiva para afrontar el periodo de quimio terapias, visualizando y haciendo consciente al paciente de los pro, contras y la importancia de la esfera emocional y afectiva en su propio cuerpo y en el afrontamiento a los posibles efectos aversivos de esta terapia.Una vez se haya iniciado su quimio terapia se ir=C3=A1n determinando distintas estrategias para seguir el curso de las visitas dependiendo de las necesidades manifestadas.</div>
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Medicamentos Indicados</div>
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Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
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Month</option>
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January</option>
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March</option>
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April</option>
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5</option>
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6</option>
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7</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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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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1899</option>
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1900</option>
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1901</option>
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1903</option>
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1906</option>
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1911</option>
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1914</option>
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1915</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1926</option>
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1927</option>
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1929</option>
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1930</option>
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1932</option>
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1933</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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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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1966</option>
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1968</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
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1984</option>
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1985</option>
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1986</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
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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>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
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2032</option>
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2033</option>
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2034</option>
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2035</option>
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2036</option>
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2037</option>
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2038</option>
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2039</option>
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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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Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_-3937552209261337507ss-q-help m_-3937552209261337507ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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Preparaci=C3=B3n afectiva para quimio terapias y posteriormente se definiran las proximas estrategias de acuerdo a las necesidades del curso del paciente y su evoluci=C3=B3n.</div>
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Derivaci=C3=B3n a otro Prestador Domiciliario</div>
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S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
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ENFERMERA</span>
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<span class=3D"m_-3937552209261337507ss-choice-label">
TENS</span>
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NUTRICIONISTA</span>
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KINESIOLOGO</span>
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PSICOLOGO</span>
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<h2 class=3D"m_-3937552209261337507ss-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_-3937552209261337507ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
</form>
</div>
</div>
</td>
</tr>
<tr height=3D"24px">
</tr>
</tbody>
</table>
</div>
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"max-width:672px;min-width:154px" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242;font-size:13px" target=3D"_blank">
Create your own Google Form</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
<div id=3D"DAB4FAD8-2DD7-40BB-A1B8-4E2AA1F9FDF2">
<br>
 <table style=3D"border-top:1px solid #d3d4de">
	<tr>
      <td style=3D"width:55px;padding-top:18px">
<a href=3D"http://www.avg.com/email-signature?utm_medium=3Demail&amp;utm_source=3Dlink&amp;utm_campaign=3Dsig-email&amp;utm_content=3Dwebmail" target=3D"_blank">
<img src=3D"https://ipmcdn.avast.com/images/icons/icon-envelope-tick-green-avg-v1.png" alt==3D"" width=3D"46" height=3D"29" style=3D"width: 46px; height: 29px;">
</a>
</td>
		<td style=3D"width:470px;padding-top:17px;color:#41424e;font-size:13px;font-family:Arial,Helvetica,sans-serif;line-height:18px">
Libre de virus. <a href=3D"http://www.avg.com/email-signature?utm_medium=3Demail&amp;utm_source=3Dlink&amp;utm_campaign=3Dsig-email&amp;utm_content=3Dwebmail" target=3D"_blank" style=3D"color:#4453ea">
www.avg.com</a>
 		</td>
	</tr>
</table>
<a href=3D"#DAB4FAD8-2DD7-40BB-A1B8-4E2AA1F9FDF2" width=3D"1" height=3D"1">
</a>
</div>
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