<div dir=3D"ltr">
Estimada, junto con saludar env=C3=ADo formulario de atenci=C3=B3n kin=C3=A9sica realizada al paciente Luis Soto.<div>
Esperando que tenga un buen=C2=A0d=C3=ADa<br>
<br>
Saludos<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"auto">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: mi=C3=A9., 5 jun. 2019 a las 0:41<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:fallendes.o@gmail.com">
fallendes.o@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 rellenar <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">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_-2560092176229677401ss-form-container">
<div class=3D"m_-2560092176229677401ss-form-heading">
<h1 class=3D"m_-2560092176229677401ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_-2560092176229677401ss-form-desc m_-2560092176229677401ss-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_-2560092176229677401ss-form">
<form method=3D"GET" id=3D"m_-2560092176229677401ss-form" target=3D"_blank">
<br>
<div class=3D"m_-2560092176229677401ss-form-question m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-item-required m_-2560092176229677401ss-text" style=3D"margin:12px 0">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2560092176229677401ss-q-item-label" for=3D"m_-2560092176229677401emailAddress">
<div class=3D"m_-2560092176229677401ss-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_-2560092176229677401emailAddress">
</label>
<span class=3D"m_-2560092176229677401ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_-2560092176229677401ss-q-text m_-2560092176229677401ss-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:fallendes.o@gmail.com" target=3D"_blank">
fallendes.o@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-2560092176229677401ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_-2560092176229677401ss-page-description m_-2560092176229677401ss-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_-2560092176229677401ss-form-question m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-item-required m_-2560092176229677401ss-text" style=3D"margin:12px 0">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2560092176229677401ss-q-item-label" for=3D"m_-2560092176229677401entry_579114469">
<div class=3D"m_-2560092176229677401ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_-2560092176229677401itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2560092176229677401ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2560092176229677401ss-q-help m_-2560092176229677401ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-2560092176229677401ss-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%">
Fernando Allendes</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2560092176229677401ss-form-question m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-item-required m_-2560092176229677401ss-text" style=3D"margin:12px 0">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2560092176229677401ss-q-item-label" for=3D"m_-2560092176229677401entry_1276273985">
<div class=3D"m_-2560092176229677401ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_-2560092176229677401itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2560092176229677401ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2560092176229677401ss-q-help m_-2560092176229677401ss-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_-2560092176229677401ss-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%">
17885100-4</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2560092176229677401ss-form-question m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-item-required m_-2560092176229677401ss-select" style=3D"margin:12px 0">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2560092176229677401ss-q-item-label" for=3D"m_-2560092176229677401entry_133691676">
<div class=3D"m_-2560092176229677401ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_-2560092176229677401itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2560092176229677401ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2560092176229677401ss-q-help m_-2560092176229677401ss-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_-2560092176229677401entry_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 selected>
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_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-2560092176229677401ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_-2560092176229677401ss-page-description m_-2560092176229677401ss-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_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-2560092176229677401ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_-2560092176229677401ss-section-description m_-2560092176229677401ss-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_-2560092176229677401ss-form-question m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-item-required m_-2560092176229677401ss-text" style=3D"margin:12px 0">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2560092176229677401ss-q-item-label" for=3D"m_-2560092176229677401entry_823811303">
<div class=3D"m_-2560092176229677401ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_-2560092176229677401itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2560092176229677401ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2560092176229677401ss-q-help m_-2560092176229677401ss-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_-2560092176229677401ss-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%">
6131208-0</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2560092176229677401ss-form-question m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-item-required m_-2560092176229677401ss-text" style=3D"margin:12px 0">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2560092176229677401ss-q-item-label" for=3D"m_-2560092176229677401entry_1959365839">
<div class=3D"m_-2560092176229677401ss-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_-2560092176229677401itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2560092176229677401ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2560092176229677401ss-q-help m_-2560092176229677401ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-2560092176229677401ss-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 Soto</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2560092176229677401ss-form-question m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-item-required m_-2560092176229677401ss-select" style=3D"margin:12px 0">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2560092176229677401ss-q-item-label" for=3D"m_-2560092176229677401entry_545002227">
<div class=3D"m_-2560092176229677401ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_-2560092176229677401itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2560092176229677401ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2560092176229677401ss-q-help m_-2560092176229677401ss-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_-2560092176229677401entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled selected>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled>
COLMENA</option>
 <option value=3D"CONSALUD" disabled>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled>
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_-2560092176229677401ss-form-question m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-item-required m_-2560092176229677401ss-text" style=3D"margin:12px 0">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2560092176229677401ss-q-item-label" for=3D"m_-2560092176229677401entry_1900161356">
<div class=3D"m_-2560092176229677401ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_-2560092176229677401itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2560092176229677401ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2560092176229677401ss-q-help m_-2560092176229677401ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-2560092176229677401ss-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%">
Talca</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2560092176229677401ss-form-question m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-item-required m_-2560092176229677401ss-text" style=3D"margin:12px 0">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2560092176229677401ss-q-item-label" for=3D"m_-2560092176229677401entry_1298871758">
<div class=3D"m_-2560092176229677401ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_-2560092176229677401itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2560092176229677401ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2560092176229677401ss-q-help m_-2560092176229677401ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-2560092176229677401ss-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%">
Talca</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-2560092176229677401ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_-2560092176229677401ss-page-description m_-2560092176229677401ss-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_-2560092176229677401ss-form-question m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-item-required m_-2560092176229677401ss-radio" style=3D"margin:12px 0">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2560092176229677401ss-q-item-label" for=3D"m_-2560092176229677401entry_2073233714">
<div class=3D"m_-2560092176229677401ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_-2560092176229677401itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2560092176229677401ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2560092176229677401ss-q-help m_-2560092176229677401ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_-2560092176229677401ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-2560092176229677401ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-2560092176229677401ss-choice-item-control m_-2560092176229677401goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_-2560092176229677401group_1222378237_1" class=3D"m_-2560092176229677401ss-q-radio">
</span>
<span class=3D"m_-2560092176229677401ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_-2560092176229677401ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-2560092176229677401ss-choice-item-control m_-2560092176229677401goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_-2560092176229677401group_1222378237_2" class=3D"m_-2560092176229677401ss-q-radio">
</span>
<span class=3D"m_-2560092176229677401ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2560092176229677401ss-form-question m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-item-required m_-2560092176229677401ss-date" style=3D"margin:12px 0">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2560092176229677401ss-q-item-label" for=3D"m_-2560092176229677401entry_1705849412">
<div class=3D"m_-2560092176229677401ss-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_-2560092176229677401itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2560092176229677401ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2560092176229677401ss-q-help m_-2560092176229677401ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-2560092176229677401ss-q-date">
<div class=3D"m_-2560092176229677401ss-datetime-box m_-2560092176229677401goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name=3D"entry.1705849412_day" disabled class=3D"m_-2560092176229677401ss-day-dropdown" id=3D"m_-2560092176229677401entry.1705849412_day">
<option value=3D"">
D==C3=ADa</option>
<option value=3D"1">
1</option>
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2</option>
 <option value=3D"3">
3</option>
 <option value=3D"4" selected>
4</option>
 <option value=3D"5">
5</option>
 <option value=3D"6">
6</option>
 <option value=3D"7">
7</option>
 <option value=3D"8">
8</option>
 <option value=3D"9">
9</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value==3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
</select>
   <select name=3D"entry.1705849412_month" disabled class=3D"m_-2560092176229677401ss-month-dropdown" id=3D"m_-2560092176229677401entry.1705849412_month">
<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
 <option value=3D"2">
febrero</option>
 <option value=3D"3">
marzo</option>
 <option value=3D"4">
abril</option>
 <option value=3D"5">
mayo</option>
 <option value=3D"6" selected>
junio</option>
 <option value=3D"7">
julio</option>
 <option value=3D"8">
agosto</option>
 <option value=3D"9">
septiembre</option>
 <option value=3D"10">
octubre</option>
 <option value=3D"11">
noviembre</option>
 <option value=3D"12">
diciembre</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_-2560092176229677401entry.1705849412_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
 <option value=3D"1898">
1898</option>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
1901</option>
 <option value=3D"1902">
1902</option>
 <option value=3D"1903">
1903</option>
 <option value=3D"1904">
1904</option>
 <option value=3D"1905">
1905</option>
 <option value=3D"1906">
1906</option>
 <option value=3D"1907">
1907</option>
 <option value=3D"1908">
1908</option>
 <option value=3D"1909">
1909</option>
 <option value=3D"1910">
1910</option>
 <option value=3D"1911">
1911</option>
 <option value=3D"1912">
1912</option>
 <option value=3D"1913">
1913</option>
 <option value=3D"1914">
1914</option>
 <option value=3D"1915">
1915</option>
 <option value=3D"1916">
1916</option>
 <option value=3D"1917">
1917</option>
 <option value=3D"1918">
1918</option>
 <option value=3D"1919">
1919</option>
 <option value=3D"1920">
1920</option>
 <option value=3D"1921">
1921</option>
 <option value=3D"1922">
1922</option>
 <option value=3D"1923">
1923</option>
 <option value==3D"1924">
1924</option>
 <option value=3D"1925">
1925</option>
 <option value==3D"1926">
1926</option>
 <option value=3D"1927">
1927</option>
 <option value==3D"1928">
1928</option>
 <option value=3D"1929">
1929</option>
 <option value==3D"1930">
1930</option>
 <option value=3D"1931">
1931</option>
 <option value==3D"1932">
1932</option>
 <option value=3D"1933">
1933</option>
 <option value==3D"1934">
1934</option>
 <option value=3D"1935">
1935</option>
 <option value==3D"1936">
1936</option>
 <option value=3D"1937">
1937</option>
 <option value==3D"1938">
1938</option>
 <option value=3D"1939">
1939</option>
 <option value==3D"1940">
1940</option>
 <option value=3D"1941">
1941</option>
 <option value==3D"1942">
1942</option>
 <option value=3D"1943">
1943</option>
 <option value==3D"1944">
1944</option>
 <option value=3D"1945">
1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
1948</option>
 <option value=3D"1949">
1949</option>
 <option value==3D"1950">
1950</option>
 <option value=3D"1951">
1951</option>
 <option value==3D"1952">
1952</option>
 <option value=3D"1953">
1953</option>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
 <option value=3D"1959">
1959</option>
 <option value==3D"1960">
1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
1976</option>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
 <option value==3D"1980">
1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
 <option value=3D"2011">
2011</option>
 <option value==3D"2012">
2012</option>
 <option value=3D"2013">
2013</option>
 <option value==3D"2014">
2014</option>
 <option value=3D"2015">
2015</option>
 <option value==3D"2016">
2016</option>
 <option value=3D"2017">
2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <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>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2560092176229677401ss-form-question m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-item-required m_-2560092176229677401ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2560092176229677401ss-q-item-label" for=3D"m_-2560092176229677401entry_206244955">
<div class=3D"m_-2560092176229677401ss-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_-2560092176229677401itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2560092176229677401ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2560092176229677401ss-q-help m_-2560092176229677401ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-2560092176229677401ss-q-time">
<div class=3D"m_-2560092176229677401ss-datetime-box m_-2560092176229677401goog-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_-2560092176229677401entry.206244955_hour">
<option value=3D"">
h</option>
<option value=3D"00">
00</option>
 <option value=3D"01">
01</option>
 <option value=3D"02">
02</option>
 <option value=3D"03">
03</option>
 <option value=3D"04">
04</option>
 <option value=3D"05">
05</option>
 <option value=3D"06">
06</option>
 <option value=3D"07">
07</option>
 <option value=3D"08">
08</option>
 <option value=3D"09">
09</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16" selected>
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value==3D"22">
22</option>
 <option value=3D"23">
23</option>
</select>
:<select name=3D"entry.206244955_minute" disabled id=3D"m_-2560092176229677401entry.206244955_minute">
<option value=3D"">
min</option>
<option value=3D"00" selected>
00</option>
 <option value=3D"01">
01</option>
 <option value=3D"02">
02</option>
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03</option>
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04</option>
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05</option>
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06</option>
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07</option>
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08</option>
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09</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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32</option>
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33</option>
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34</option>
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35</option>
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36</option>
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37</option>
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38</option>
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39</option>
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40</option>
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41</option>
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42</option>
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43</option>
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44</option>
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45</option>
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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>
 <option value=3D"58">
58</option>
 <option value=3D"59">
59</option>
</select>
<div class=3D"m_-2560092176229677401ss-datetime-box-spacer m_-2560092176229677401goog-inline-block" style=3D"height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2560092176229677401ss-form-question m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-item-required m_-2560092176229677401ss-select" style=3D"margin:12px 0">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2560092176229677401ss-q-item-label" for=3D"m_-2560092176229677401entry_1747608258">
<div class=3D"m_-2560092176229677401ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_-2560092176229677401itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-2560092176229677401ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-2560092176229677401ss-q-help m_-2560092176229677401ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.1747608258" disabled id=3D"m_-2560092176229677401entry_1747608258">
<option value=3D"">
</option>
<option value=3D"0" disabled>
0</option>
 <option value=3D"1" disabled>
1</option>
 <option value=3D"2" disabled>
2</option>
 <option value=3D"3" disabled>
3</option>
 <option value=3D"4" disabled selected>
4</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-2560092176229677401ss-form-question m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2560092176229677401ss-q-item-label" for=3D"m_-2560092176229677401entry_1716090865">
<div class=3D"m_-2560092176229677401ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_-2560092176229677401ss-q-help m_-2560092176229677401ss-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_-2560092176229677401entry_1421689035">
<tbody>
<tr>
<td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1421689035_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1421689035_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-2560092176229677401ss-scalerow m_-2560092176229677401ss-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_-2560092176229677401aria-todo">
</div>
</td>
<td class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"0" id=3D"m_-2560092176229677401group_1421689035_1" class=3D"m_-2560092176229677401ss-q-radio">
</div>
</td>
 <td class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"1" id=3D"m_-2560092176229677401group_1421689035_2" class=3D"m_-2560092176229677401ss-q-radio">
</div>
</td>
 <td class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"2" id=3D"m_-2560092176229677401group_1421689035_3" class==3D"m_-2560092176229677401ss-q-radio">
</div>
</td>
 <td class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3" id=3D"m_-2560092176229677401group_1421689035_4" class=3D"m_-2560092176229677401ss-q-radio">
</div>
</td>
 <td class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_-2560092176229677401group_1421689035_5" class=3D"m_-2560092176229677401ss-q-radio">
</div>
</td>
 <td class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_-2560092176229677401group_1421689035_6" class=3D"m_-2560092176229677401ss-q-radio">
</div>
</td>
 <td class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_-2560092176229677401group_1421689035_7" class=3D"m_-2560092176229677401ss-q-radio">
</div>
</td>
 <td class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"7" id=3D"m_-2560092176229677401group_1421689035_8" class=3D"m_-2560092176229677401ss-q-radio">
</div>
</td>
 <td class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_-2560092176229677401group_1421689035_9" class=3D"m_-2560092176229677401ss-q-radio">
</div>
</td>
 <td class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_-2560092176229677401group_1421689035_10" class=3D"m_-2560092176229677401ss-q-radio">
</div>
</td>
 <td class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled checked value=3D"10" id=3D"m_-2560092176229677401group_1421689035_11" class=3D"m_-2560092176229677401ss-q-radio">
</div>
</td>
<td class=3D"m_-2560092176229677401ss-scalerow m_-2560092176229677401ss-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_-2560092176229677401ss-form-question m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2560092176229677401ss-q-item-label" for=3D"m_-2560092176229677401entry_2064050596">
<div class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-q-help m_-2560092176229677401ss-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_-2560092176229677401entry_1244707512">
<tbody>
<tr>
<td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1244707512_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1244707512_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-2560092176229677401ss-scalenumber" for=3D"m_-2560092176229677401group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-2560092176229677401ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-2560092176229677401ss-scalerow m_-2560092176229677401ss-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_-2560092176229677401aria-todo">
</div>
</td>
<td class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"0" id=3D"m_-2560092176229677401group_1244707512_1" class=3D"m_-2560092176229677401ss-q-radio">
</div>
</td>
 <td class=3D"m_-2560092176229677401ss-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_-2560092176229677401ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"1" id=3D"m_-2560092176229677401group_1244707512_2" class=3D"m_-2560092176229677401ss-q-radio">
</div>
</td>
 <td class=3D"m_-2560092176229677401ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
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Escala Dolor EVA M=C3=ADnimo</div>
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0</label>
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1</label>
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2</label>
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3</label>
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4</label>
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5</label>
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6</label>
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7</label>
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8</label>
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9</label>
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10</label>
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<div class=3D"m_-2560092176229677401ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
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Paciente de antecedentes conocidos, pareja refiere que se ha encontrado deca=C3=ADdo, se niega a comer, por lo que est=C3=A1 alimentado solo con glucerna m=C3=A1s agregados. Lleva 4 d=C3==ADas en reposo en cama, solo levant=C3=A1ndose al ba=C3=B1o. Paciente refiere sentir dolor intenso siempre y adem=C3=A1s gran cansancio.</div>
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<div class=3D"m_-2560092176229677401ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen F=C3=ADsico<label for=3D"m_-2560092176229677401itemView.getDomIdToLabel()">
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Paciente se encuentra acostado, orientado, con FiO2 ambiental. Par=C3=A1metros basales FC 66x&#39;; FR 20cpm; SatO2 89%, inmediatamente aplico O2 adicional 2 L/min por naricera, aumentando SatO2 a 98%. MP (+) disminuido en =C3=A1pice derecho y ambas bases SRA. Se realiza SBC bien tolerado y bipedestaci=C3=B3n bien tolerado, pero con cierta inseguridad, por lo que mantengo apoyo con manos para entregar estabilidad. Se realiza masoterapia en hombro derecho el cual refiere entregar un gran alivio del dolor que presenta.</div>
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<div class=3D"m_-2560092176229677401ss-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%">
Disfunci=C3=B3n severa caracterizada por reposo prolongado, dolor intenso, fatiga e intolerancia al esfuerzo asociado por compromiso cardiopulmonar</div>
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Plan de Tratamiento e Indicaciones<label for=3D"m_-2560092176229677401itemView.getDomIdToLabel()">
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<span class=3D"m_-2560092176229677401ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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Mejorar volumen corriente, disminuir reposo, disminuir fatiga</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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<div class=3D"m_-2560092176229677401ss-datetime-box m_-2560092176229677401goog-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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D==C3=ADa</option>
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1</option>
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2</option>
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3</option>
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4</option>
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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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Mes</option>
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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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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>
 <option value==3D"1932">
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>
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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>
 <option value==3D"2000">
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>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
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>
 <option value=3D"2026">
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>
 <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>
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2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
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2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
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 <div class=3D"m_-2560092176229677401ss-form-question m_-2560092176229677401errorbox-good">
<div dir=3D"auto" class=3D"m_-2560092176229677401ss-item m_-2560092176229677401ss-text" style=3D"margin:12px 0">
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Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_-2560092176229677401ss-q-help m_-2560092176229677401ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-2560092176229677401ss-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%">
O2 permanente, localizaci=C3=B3n diafragm=C3=A1tica, SBC y bipedestaci=C3=B3n adem=C3=A1s de marcha est=C3=A1tica a tolerancia. Masoterapia en hombro derecho</div>
</div>
</div>
</div>
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<div class=3D"m_-2560092176229677401ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-2560092176229677401ss-q-item-label" for=3D"m_-2560092176229677401entry_1219705969">
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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>
</label>
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<span class=3D"m_-2560092176229677401ss-choice-label">
ENFERMERA</span>
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<label>
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<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_-2560092176229677401group_503039759_2" class=3D"m_-2560092176229677401ss-q-checkbox">
</span>
<span class=3D"m_-2560092176229677401ss-choice-label">
TENS</span>
</label>
</li>
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<label>
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<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id==3D"m_-2560092176229677401group_503039759_3" class=3D"m_-2560092176229677401ss-q-checkbox">
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NUTRICIONISTA</span>
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<label>
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<span class=3D"m_-2560092176229677401ss-choice-label">
KINESIOLOGO</span>
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<label>
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PSICOLOGO</span>
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<h2 class=3D"m_-2560092176229677401ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
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<img class=3D"m_-2560092176229677401ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
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</form>
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<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242;font-size:13px" target=3D"_blank">
Crea tu propio formulario de Google</a>
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Allendes Osorio</i>
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Lic. en Kinesiolog=C3=ADa</font>
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