<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">
Formularios de Google</strong>
 <span dir=3D"ltr">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: mi=C3=A9., 15 may. 2019 a las 12:01<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:gbarkerm@gmail.com">
gbarkerm@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding==3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt==3D"Formularios de Google" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align==3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por llenar <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target=3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Estas son tus respuestas:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_-4140748835427396366ss-form-container">
<div class=3D"m_-4140748835427396366ss-form-heading">
<h1 class=3D"m_-4140748835427396366ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_-4140748835427396366ss-form-desc m_-4140748835427396366ss-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_-4140748835427396366ss-form">
<form method=3D"GET" id=3D"m_-4140748835427396366ss-form" target=3D"_blank">
<br>
<div class=3D"m_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-item-required m_-4140748835427396366ss-text" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366emailAddress">
<div class=3D"m_-4140748835427396366ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Direcci=C3=B3n de correo electr=C3=B3nico<label for=3D"m_-4140748835427396366emailAddress">
</label>
<span class=3D"m_-4140748835427396366ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_-4140748835427396366ss-q-text m_-4140748835427396366ss-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:gbarkerm@gmail.com" target=3D"_blank">
gbarkerm@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-4140748835427396366ss-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_-4140748835427396366ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-4140748835427396366ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_-4140748835427396366ss-page-description m_-4140748835427396366ss-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_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-item-required m_-4140748835427396366ss-text" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366entry_579114469">
<div class=3D"m_-4140748835427396366ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_-4140748835427396366itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4140748835427396366ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4140748835427396366ss-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%">
Guillermo Barker Maillard</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-item-required m_-4140748835427396366ss-text" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366entry_1276273985">
<div class=3D"m_-4140748835427396366ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_-4140748835427396366itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4140748835427396366ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-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_-4140748835427396366ss-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%">
16608219-6</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-item-required m_-4140748835427396366ss-select" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366entry_133691676">
<div class=3D"m_-4140748835427396366ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_-4140748835427396366itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4140748835427396366ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-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_-4140748835427396366entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled selected>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-4140748835427396366ss-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_-4140748835427396366ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-4140748835427396366ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_-4140748835427396366ss-page-description m_-4140748835427396366ss-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_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-4140748835427396366ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_-4140748835427396366ss-section-description m_-4140748835427396366ss-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_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-item-required m_-4140748835427396366ss-text" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366entry_823811303">
<div class=3D"m_-4140748835427396366ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_-4140748835427396366itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4140748835427396366ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-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_-4140748835427396366ss-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%">
5681099-4</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-item-required m_-4140748835427396366ss-text" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366entry_1959365839">
<div class=3D"m_-4140748835427396366ss-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_-4140748835427396366itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4140748835427396366ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4140748835427396366ss-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%">
Jorge Reyes Pradena</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-item-required m_-4140748835427396366ss-select" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366entry_545002227">
<div class=3D"m_-4140748835427396366ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_-4140748835427396366itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4140748835427396366ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-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_-4140748835427396366entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled>
COLMENA</option>
 <option value=3D"CONSALUD" disabled>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled selected>
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled>
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled>
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-item-required m_-4140748835427396366ss-text" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366entry_1900161356">
<div class=3D"m_-4140748835427396366ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_-4140748835427396366itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4140748835427396366ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4140748835427396366ss-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%">
Frutillar </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-item-required m_-4140748835427396366ss-text" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366entry_1298871758">
<div class=3D"m_-4140748835427396366ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_-4140748835427396366itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4140748835427396366ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4140748835427396366ss-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%">
Frutillar </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-4140748835427396366ss-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_-4140748835427396366ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-4140748835427396366ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_-4140748835427396366ss-page-description m_-4140748835427396366ss-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_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-item-required m_-4140748835427396366ss-radio" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366entry_2073233714">
<div class=3D"m_-4140748835427396366ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_-4140748835427396366itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4140748835427396366ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_-4140748835427396366ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-4140748835427396366ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-4140748835427396366ss-choice-item-control m_-4140748835427396366goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_-4140748835427396366group_1222378237_1" class=3D"m_-4140748835427396366ss-q-radio">
</span>
<span class=3D"m_-4140748835427396366ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_-4140748835427396366ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-4140748835427396366ss-choice-item-control m_-4140748835427396366goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_-4140748835427396366group_1222378237_2" class=3D"m_-4140748835427396366ss-q-radio">
</span>
<span class=3D"m_-4140748835427396366ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-item-required m_-4140748835427396366ss-date" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366entry_1705849412">
<div class=3D"m_-4140748835427396366ss-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_-4140748835427396366itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4140748835427396366ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4140748835427396366ss-q-date">
<div class=3D"m_-4140748835427396366ss-datetime-box m_-4140748835427396366goog-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"">
Mes</option>
<option value=3D"1">
enero</option>
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febrero</option>
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marzo</option>
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abril</option>
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mayo</option>
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junio</option>
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julio</option>
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agosto</option>
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septiembre</option>
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octubre</option>
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noviembre</option>
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diciembre</option>
</select>
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<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_-4140748835427396366entry.1705849412_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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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>
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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>
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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>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
 <option value==3D"1980">
1980</option>
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1981</option>
 <option value==3D"1982">
1982</option>
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1983</option>
 <option value==3D"1984">
1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
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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>
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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>
 <option value=3D"2051">
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>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-item-required m_-4140748835427396366ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366entry_206244955">
<div class=3D"m_-4140748835427396366ss-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_-4140748835427396366itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4140748835427396366ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4140748835427396366ss-q-time">
<div class=3D"m_-4140748835427396366ss-datetime-box m_-4140748835427396366goog-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_-4140748835427396366entry.206244955_hour">
<option value=3D"">
h</option>
<option value=3D"00">
00</option>
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01</option>
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02</option>
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03</option>
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04</option>
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05</option>
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06</option>
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07</option>
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08</option>
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09</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
</select>
.<select name=3D"entry.206244955_minute" disabled id=3D"m_-4140748835427396366entry.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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20</option>
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21</option>
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22</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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54</option>
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55</option>
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56</option>
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Performance Status ECOG del Paciente<label for=3D"m_-4140748835427396366itemView.getDomIdToLabel()">
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<span class=3D"m_-4140748835427396366ss-required-asterisk" style=3D"color:#c43b1d">
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3</option>
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<div class=3D"m_-4140748835427396366ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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0</label>
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3</label>
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5</label>
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10</label>
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Escala Dolor EVA M=C3=A1ximo</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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0</label>
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<label class=3D"m_-4140748835427396366ss-scalenumber" for=3D"m_-4140748835427396366group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
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2</label>
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3</label>
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<label class=3D"m_-4140748835427396366ss-scalenumber" for=3D"m_-4140748835427396366group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
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<label class=3D"m_-4140748835427396366ss-scalenumber" for=3D"m_-4140748835427396366group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
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<label class=3D"m_-4140748835427396366ss-scalenumber" for=3D"m_-4140748835427396366group_1244707512_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
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7</label>
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8</label>
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9</label>
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Escala Dolor EVA M=C3=ADnimo</div>
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0</label>
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Paciente con antecedentes descritos, 2 esquemas de 12 ciclos de QMT terminados con buena tolerancia. Iniciando un 3 esquema de QT de 4 ciclos (segundo completado). Antecedente de NAC en noviembre de 2018, que requiri=C3=B3 de hospitalizaci=C3=B3n.=20El d=C3=ADa 26 de diciembre paciente presenta episodio de lumbalgia muy intenso irradiado a extremidades inferiores. Por refractaridad de dolor a analgesia (AINES, paracetamol, morfina) paciente decide consultar en servicio de urgencias, donde se requiere de morfina EV (10 mg) para manejo del dolor con alivio parcial. Se realiza scanner donde se informa extenso compromiso metast=C3=A1sico nodular pulmonar bilateral y hep=C3=A1tico en LD con cambios morfol=C3=B3gicos asociados de este =C3=BAltimo =C3=B3rgano y dilataci==C3=B3n de la v=C3=ADa biliar intrahep=C3=A1tica derecha, compromiso de aspecto neopl=C3=A1sico secundario en columna lumbar. Tambi=C3=A9n se realiza scanner de cerebro donde se describe leves cambios involutivos encef=C3=A1licos difusos asociados a ligeros signos de microangiopatia de la sustancia blanca supratentorial.=20Present=C3=B3 nueva crisis de dolor el 31 de diciembre y el 1 de enero que requiere de morfina para yugular el dolor.=20Con scanner obtenido en servicio de urgencias Cl=C3=ADnica Puerto Varas, se realiza an=C3=A1lisis comparativo con scanner de octubre, donde se vio aumento de n=C3=B3dulos pulmonares significativa, aumento de masa hep=C3=A1tica de 2,8 a 3,5 cm; sin cambios evidentes en met=C3=A1stasis lumbar.=20Por progresi=C3=B3n de enfermedad, equipo de oncolog=C3=ADa decide reinicio de QMT esquema FOLFOX. Se inicia esquema de 4 ciclos el martes 29 de enero. Primer ciclo muy mal tolerado, paciente evoluciona 7 d=C3=ADas con rechazo alimentario (no ingiere alimentos primeros 3 d=C3=ADas), diarrea profusa, alzas t=C3=A9rmicas hasta 40=C2=BAC, y mucho dolor (EVA 10/10). Se realiza ajuste de quimio, completandose el 2=C2=BA ciclo 6 semanas despu=C3=A9s (5/3/2019) con mucha mejor tolerancia. 3=C2=BA ciclo de quimio tambi=C3=A9n bien tolerado. Pendiente 4 ciclo (que debi=C3=B3 iniciarse el 4 de abril)Se realiza evaluaci=C3=B3n por odontolog=C3=ADa, pendiente emisi=C3=B3n de certificado que autoriza uso de pamidronato.=20El 17 de diciembre, en relaci=C3=B3n a retraso en cambio de parches, paciente presenta episodio de dolor progresivo hasta EVA 10/10 y diarrea. Es llevado a servicio de urgencias de cl=C3=ADnica puerto varas donde ingresa en regulares condiciones generales, somnolientas, tendencia a la hipotension y subfebriles. Se hospitaliza para estabilizaci=C3=B3n, siendo dado de alta el 20 de diciembre.=20Lunes 29 de Abril se cambia a Durogesic 50 mcg/d 1 parche y fentora 100 mcg SOS=20Al momento de la evaluaci=C3=B3n, paciente con escala ECOG 3. Con esquema actual de analgesia, paciente necesita estar en cama m=C3=A1s de la mitad del d=C3=ADa por la presencia de s=C3=ADntomas. Necesita ayuda para la mayor==C3=ADa de las actividades de la vida diaria. Paciente requiere visitas SOS para administraci=C3=B3n de AINES EV para alivio de dolor, con buena respuesta. Por uso de fentora frecuente se sube dosis de parche a 75 mcg/dDesde el punto de vista afectivo, paciente refiere =C3=A1nimo bajo la mayor parte del tiempo e ideas de muerte (sin ideacion suicida activa y sin alucinaciones). Hija refiere gran labilidad emocional e irritabilidad. En el contexto de esto, presenta relaci=C3=B3n conflictiva con parte del equipo tratante</div>
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Examen F=C3=ADsico<label for=3D"m_-4140748835427396366itemView.getDomIdToLabel()">
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PA: 120/78 FC: 76 FR: 12 T=C2=B0: 36==C2=B0C SatO2: 98%=20Estable. En cama por dolor. Bien hidratado y perfundido. Piel sana. Sin adenopat=C3=ADas palpables. RR2TNAS MP (+) SRA actuales. Abd. BDI RHA (+). Sin masas ni visceromegalias palpables. Sensibilidad a palpaci=C3=B3n de musculatura paravertebral lumbar y cuerpos vertebrales muy marcada a nivel de L4-L5. Sin cambios inflamatorios cut=C3=A1neos. EEII sin edemas ni signos de TVP. Tepe y lasegue dudosos. Examen neurol=C3=B3gico normal. Sin evidencias de UPP</div>
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<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4140748835427396366ss-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%">
C=C3=A1ncer de colon metast=C3=A1sico, Met=C3=A1stasis lumbar, Trastorno del animo -&gt; Obs trastorno depresivo mayor, Lumbociatica, DM2 IR, HTA</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-item-required m_-4140748835427396366ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366entry_1255665248">
<div class=3D"m_-4140748835427396366ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_-4140748835427396366itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4140748835427396366ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4140748835427396366ss-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%">
-Por lumbalgia persistente en contexto de met=C3=A1stasis lumbar, insisto en evaluaci=C3=B3n de radioterapia=20-Refuerzo importancia de apoyo por equipo de salud mental. Mantengo indicaci=C3=B3n de evaluaci=C3=B3n por psicolog=C3=ADa.-Visitas por enfermer=C3=ADa SOS en caso de dolor (1-2 por semana)=20-R=C3=A9gimen hipos=C3=B3dico e hipogluc=C3=ADdico (200 gr de hidratos de carbono)-Durogesic 50 mcg/d; 1 de parche cada 3 d=C3=ADas. Rotar de posicion.=20-Fentora 100 mcg, 1 comp SOS (explico su uso)-Paracetamol 500 mg, 2 como cada 8 hrs via oral =20-Paracetamol 1gr EV, 1 amp SOS-Ketorolaco 30 mg EV SOS=20-Dipirona 1 gr EV SOS-Diclofenaco 75 mg IM SOS-Dacam Rapilento 1 amp IM SOS en caso de dolor m=C3=A1ximo cada 2 semanas ==20-Ondasentron 4 mg SOS en caso de nauseas y vomitos=20-Lactulosa 20 cc SOS en caso de constipacion=20-Pamidronato 90 mg EV lento mensual por 6 meses (reevaluar seg=C3=BAn tolerancia y monitorizando efectos adversos -&gt; explico)=20-Terapia kinesica motora por lumbociatica =20-Por dificultad en manejo del dolor y trastorno de =C3=A1nimo, indico evaluaci=C3=B3n m=C3=A9dica 3 veces por semana=20-Sin cambios en tratamiento cr=C3=B3nico </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366entry_1648939075">
<div class=3D"m_-4140748835427396366ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4140748835427396366ss-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%">
-Por lumbalgia persistente en contexto de met=C3=A1stasis lumbar, insisto en evaluaci=C3=B3n de radioterapia=20-Refuerzo importancia de apoyo por equipo de salud mental. Mantengo indicaci=C3=B3n de evaluaci=C3=B3n por psicolog=C3=ADa.-Visitas por enfermer=C3=ADa SOS en caso de dolor (1-2 por semana)=20-R=C3=A9gimen hipos=C3=B3dico e hipogluc=C3=ADdico (200 gr de hidratos de carbono)-Durogesic 50 mcg/d; 1 de parche cada 3 d=C3=ADas. Rotar de posicion.=20-Fentora 100 mcg, 1 comp SOS (explico su uso)-Paracetamol 500 mg, 2 como cada 8 hrs via oral =20-Paracetamol 1gr EV, 1 amp SOS-Ketorolaco 30 mg EV SOS=20-Dipirona 1 gr EV SOS-Diclofenaco 75 mg IM SOS-Dacam Rapilento 1 amp IM SOS en caso de dolor m=C3=A1ximo cada 2 semanas ==20-Ondasentron 4 mg SOS en caso de nauseas y vomitos=20-Lactulosa 20 cc SOS en caso de constipacion=20-Pamidronato 90 mg EV lento mensual por 6 meses (reevaluar seg=C3=BAn tolerancia y monitorizando efectos adversos -&gt; explico)=20-Terapia kinesica motora por lumbociatica =20-Por dificultad en manejo del dolor y trastorno de =C3=A1nimo, indico evaluaci=C3=B3n m=C3=A9dica 3 veces por semana=20-Sin cambios en tratamiento cr=C3=B3nico </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-date" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366entry_2063615873">
<div class=3D"m_-4140748835427396366ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4140748835427396366ss-q-date">
<div class=3D"m_-4140748835427396366ss-datetime-box m_-4140748835427396366goog-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"">
Mes</option>
<option value=3D"1">
enero</option>
 <option value=3D"2">
febrero</option>
 <option value=3D"3">
marzo</option>
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abril</option>
 <option value=3D"5" selected>
mayo</option>
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junio</option>
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julio</option>
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agosto</option>
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septiembre</option>
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octubre</option>
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noviembre</option>
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diciembre</option>
</select>
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<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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=20<select name=3D"entry.2063615873_year" disabled id=3D"m_-4140748835427396366entry.2063615873_year">
<option value=3D"">
A=C3=B1o</option>
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1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1939</option>
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1940</option>
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1941</option>
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1943</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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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1956</option>
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1957</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>
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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>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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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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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>
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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>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-text" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366entry_74766472">
<div class=3D"m_-4140748835427396366ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4140748835427396366ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4140748835427396366ss-form-question m_-4140748835427396366errorbox-good">
<div dir=3D"auto" class=3D"m_-4140748835427396366ss-item m_-4140748835427396366ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_-4140748835427396366ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4140748835427396366ss-q-item-label" for=3D"m_-4140748835427396366entry_1219705969">
<div class=3D"m_-4140748835427396366ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_-4140748835427396366ss-q-help m_-4140748835427396366ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
</label>
<ul class=3D"m_-4140748835427396366ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-4140748835427396366ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-4140748835427396366ss-choice-item-control m_-4140748835427396366goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"ENFERMERA" id=3D"m_-4140748835427396366group_503039759_1" class=3D"m_-4140748835427396366ss-q-checkbox">
</span>
<span class=3D"m_-4140748835427396366ss-choice-label">
ENFERMERA</span>
</label>
</li>
 <li class=3D"m_-4140748835427396366ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-4140748835427396366ss-choice-item-control m_-4140748835427396366goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_-4140748835427396366group_503039759_2" class=3D"m_-4140748835427396366ss-q-checkbox">
</span>
<span class=3D"m_-4140748835427396366ss-choice-label">
TENS</span>
</label>
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