<div dir=3D"ltr">
<br>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class==3D"gmail_attr">
---------- Forwarded message ---------<br>
De: <b class=3D"gmail_sendername" dir=3D"auto">
Google Forms</b>
 <span dir=3D"auto">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: jue., 6 jun. 2019 a las 8:23<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:esperanza.oyarzun@gmail.com">
esperanza.oyarzun@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 style=3D"background-color:rgb(38,4,154)" border=3D"0" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Google Forms" style=3D"display:inline-block;margin:0;vertical-align:middle" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png" height=3D"26px" width=3D"143px">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px" align=3D"center">
<table style=3D"background-color:#fff" align=3D"center" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Thanks for filling out <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target=3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Here&#39;s what we got from you:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_-8845590695791215203ss-form-container">
<div class=3D"m_-8845590695791215203ss-form-heading">
<h1 class=3D"m_-8845590695791215203ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_-8845590695791215203ss-form-desc m_-8845590695791215203ss-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_-8845590695791215203ss-form">
<form method=3D"GET" id=3D"m_-8845590695791215203ss-form" target=3D"_blank">
<br>
<div class=3D"m_-8845590695791215203ss-form-question m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-item-required m_-8845590695791215203ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8845590695791215203ss-q-item-label" for=3D"m_-8845590695791215203emailAddress">
<div class=3D"m_-8845590695791215203ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Email address<label for=3D"m_-8845590695791215203emailAddress">
</label>
<span class=3D"m_-8845590695791215203ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_-8845590695791215203ss-q-text m_-8845590695791215203ss-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:esperanza.oyarzun@gmail.com" target=3D"_blank">
esperanza.oyarzun@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8845590695791215203ss-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_-8845590695791215203ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8845590695791215203ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_-8845590695791215203ss-page-description m_-8845590695791215203ss-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_-8845590695791215203ss-form-question m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-item-required m_-8845590695791215203ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8845590695791215203ss-q-item-label" for=3D"m_-8845590695791215203entry_579114469">
<div class=3D"m_-8845590695791215203ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_-8845590695791215203itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8845590695791215203ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8845590695791215203ss-q-help m_-8845590695791215203ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8845590695791215203ss-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%">
esperanza oyarzun</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8845590695791215203ss-form-question m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-item-required m_-8845590695791215203ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8845590695791215203ss-q-item-label" for=3D"m_-8845590695791215203entry_1276273985">
<div class=3D"m_-8845590695791215203ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_-8845590695791215203itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8845590695791215203ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8845590695791215203ss-q-help m_-8845590695791215203ss-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_-8845590695791215203ss-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%">
15550993-7</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8845590695791215203ss-form-question m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-item-required m_-8845590695791215203ss-select" style=3D"margin:12px 0">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8845590695791215203ss-q-item-label" for=3D"m_-8845590695791215203entry_133691676">
<div class=3D"m_-8845590695791215203ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_-8845590695791215203itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8845590695791215203ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8845590695791215203ss-q-help m_-8845590695791215203ss-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_-8845590695791215203entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled selected>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8845590695791215203ss-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_-8845590695791215203ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8845590695791215203ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_-8845590695791215203ss-page-description m_-8845590695791215203ss-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_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8845590695791215203ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_-8845590695791215203ss-section-description m_-8845590695791215203ss-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_-8845590695791215203ss-form-question m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-item-required m_-8845590695791215203ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8845590695791215203ss-q-item-label" for=3D"m_-8845590695791215203entry_823811303">
<div class=3D"m_-8845590695791215203ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_-8845590695791215203itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8845590695791215203ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8845590695791215203ss-q-help m_-8845590695791215203ss-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_-8845590695791215203ss-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%">
1899893-9</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8845590695791215203ss-form-question m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-item-required m_-8845590695791215203ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8845590695791215203ss-q-item-label" for=3D"m_-8845590695791215203entry_1959365839">
<div class=3D"m_-8845590695791215203ss-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_-8845590695791215203itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8845590695791215203ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8845590695791215203ss-q-help m_-8845590695791215203ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8845590695791215203ss-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%">
Wolfgang Guttmann</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8845590695791215203ss-form-question m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-item-required m_-8845590695791215203ss-select" style=3D"margin:12px 0">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8845590695791215203ss-q-item-label" for=3D"m_-8845590695791215203entry_545002227">
<div class=3D"m_-8845590695791215203ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_-8845590695791215203itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8845590695791215203ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8845590695791215203ss-q-help m_-8845590695791215203ss-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_-8845590695791215203entry_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 selected>
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_-8845590695791215203ss-form-question m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-item-required m_-8845590695791215203ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8845590695791215203ss-q-item-label" for=3D"m_-8845590695791215203entry_1900161356">
<div class=3D"m_-8845590695791215203ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_-8845590695791215203itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8845590695791215203ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8845590695791215203ss-q-help m_-8845590695791215203ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8845590695791215203ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Puerto Montt</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8845590695791215203ss-form-question m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-item-required m_-8845590695791215203ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8845590695791215203ss-q-item-label" for=3D"m_-8845590695791215203entry_1298871758">
<div class=3D"m_-8845590695791215203ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_-8845590695791215203itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8845590695791215203ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8845590695791215203ss-q-help m_-8845590695791215203ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8845590695791215203ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Puerto Montt</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8845590695791215203ss-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_-8845590695791215203ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8845590695791215203ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_-8845590695791215203ss-page-description m_-8845590695791215203ss-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_-8845590695791215203ss-form-question m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-item-required m_-8845590695791215203ss-radio" style=3D"margin:12px 0">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8845590695791215203ss-q-item-label" for=3D"m_-8845590695791215203entry_2073233714">
<div class=3D"m_-8845590695791215203ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_-8845590695791215203itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8845590695791215203ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8845590695791215203ss-q-help m_-8845590695791215203ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_-8845590695791215203ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-8845590695791215203ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-8845590695791215203ss-choice-item-control m_-8845590695791215203goog-inline-block" style=3D"display:inline-block">
<input name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_-8845590695791215203group_1222378237_1" class=3D"m_-8845590695791215203ss-q-radio" type=3D"radio">
</span>
<span class=3D"m_-8845590695791215203ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_-8845590695791215203ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-8845590695791215203ss-choice-item-control m_-8845590695791215203goog-inline-block" style=3D"display:inline-block">
<input name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_-8845590695791215203group_1222378237_2" class=3D"m_-8845590695791215203ss-q-radio" type==3D"radio">
</span>
<span class=3D"m_-8845590695791215203ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8845590695791215203ss-form-question m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-item-required m_-8845590695791215203ss-date" style=3D"margin:12px 0">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8845590695791215203ss-q-item-label" for=3D"m_-8845590695791215203entry_1705849412">
<div class=3D"m_-8845590695791215203ss-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_-8845590695791215203itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8845590695791215203ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8845590695791215203ss-q-help m_-8845590695791215203ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8845590695791215203ss-q-date">
<div class=3D"m_-8845590695791215203ss-datetime-box m_-8845590695791215203goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
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<option value==3D"">
Month</option>
<option value=3D"1">
January</option>
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February</option>
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March</option>
 <option value=3D"4">
April</option>
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May</option>
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June</option>
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July</option>
 <option value=3D"8">
August</option>
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September</option>
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October</option>
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November</option>
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December</option>
</select>
   <select name=3D"entry.1705849412_day" disabled class=3D"m_-8845590695791215203ss-day-dropdown" id=3D"m_-8845590695791215203entry.1705849412_day">
<option value=3D"">
Day</option>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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4</option>
 <option value=3D"5" selected>
5</option>
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6</option>
 <option value=3D"7">
7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
 <option value=3D"29">
29</option>
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30</option>
 <option value=3D"31">
31</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_-8845590695791215203entry.1705849412_year">
<option value=3D"">
Year</option>
<option value=3D"1896">
1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
 <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>
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1912</option>
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1913</option>
 <option value=3D"1914">
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>
 <option value=3D"1929">
1929</option>
 <option value==3D"1930">
1930</option>
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1931</option>
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1932</option>
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1933</option>
 <option value==3D"1934">
1934</option>
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1935</option>
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1936</option>
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1937</option>
 <option value==3D"1938">
1938</option>
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1939</option>
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1940</option>
 <option value=3D"1941">
1941</option>
 <option value==3D"1942">
1942</option>
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1943</option>
 <option value==3D"1944">
1944</option>
 <option value=3D"1945">
1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
1948</option>
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1949</option>
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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>
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1959</option>
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1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
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1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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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>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
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1980</option>
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1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
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1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
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1990</option>
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1991</option>
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1992</option>
 <option value=3D"1993">
1993</option>
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1994</option>
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1995</option>
 <option value==3D"1996">
1996</option>
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1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
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2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
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2004</option>
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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>
 <option value==3D"2018">
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>
 <option value==3D"2046">
2046</option>
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2047</option>
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2048</option>
 <option value=3D"2049">
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>
 <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_-8845590695791215203ss-form-question m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-item-required m_-8845590695791215203ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8845590695791215203ss-q-item-label" for=3D"m_-8845590695791215203entry_206244955">
<div class=3D"m_-8845590695791215203ss-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_-8845590695791215203itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8845590695791215203ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8845590695791215203ss-q-help m_-8845590695791215203ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8845590695791215203ss-q-time">
<div class=3D"m_-8845590695791215203ss-datetime-box m_-8845590695791215203goog-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_-8845590695791215203entry.206244955_hour">
<option value=3D"">
Hr</option>
<option value=3D"01">
01</option>
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02</option>
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03</option>
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04</option>
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05</option>
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06</option>
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07</option>
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08</option>
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09</option>
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10</option>
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11</option>
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12</option>
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:<select name=3D"entry.206244955_minute" disabled id=3D"m_-8845590695791215203entry.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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Performance Status ECOG del Paciente<label for=3D"m_-8845590695791215203itemView.getDomIdToLabel()">
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<div class=3D"m_-8845590695791215203ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_-8845590695791215203ss-q-help m_-8845590695791215203ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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0</label>
</td>
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<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1421689035_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_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
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<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
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6</label>
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<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
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<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
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<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
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<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
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<div class=3D"m_-8845590695791215203ss-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_-8845590695791215203ss-q-help m_-8845590695791215203ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
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</td>
<td class=3D"m_-8845590695791215203ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-8845590695791215203ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-8845590695791215203ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1244707512_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-8845590695791215203ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
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<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
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<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1244707512_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-8845590695791215203ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-8845590695791215203ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-8845590695791215203ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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<label class=3D"m_-8845590695791215203ss-scalenumber" for=3D"m_-8845590695791215203group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-8845590695791215203ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-8845590695791215203ss-scalerow m_-8845590695791215203ss-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_-8845590695791215203aria-todo">
</div>
</td>
<td class=3D"m_-8845590695791215203ss-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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</div>
</td>
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</div>
</td>
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<input name=3D"entry.1244707512" disabled value=3D"2" id=3D"m_-8845590695791215203group_1244707512_3" class=3D"m_-8845590695791215203ss-q-radio" type=3D"radio">
</div>
</td>
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Escala Dolor EVA M=C3=ADnimo</div>
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Adulto mayor de 94 a=C3=B1os con Ca de Pr=C3=B3stata, semi autovalente y sin conocimiento de su Dg y Pron=C3=B3stico. Visita de enfermera, al llegar me recibe su hija Angara (cuidadora) actualmente sola en el cuidados de sus dos padres, ya que Sra MArlene (cuidadora remunerada) se encuentra de vacaciones. Hija refiere un buen estado de salud de su padre, sin embargo por reciente caida de su madre, el paciente intenta ayudarla y lo percibe asustado y agitado.Se realiz=C3=B3 ecocardiograma y en contexto de su edad se encuentra en parametros normales. =20La recepci=C3=B3n del paciente es afectuosa, se encuentra en BCG, a la entrevista rel=C3=B1ata caida de su esposa pero sin mayores preocupaciones al respecto ya que no fue severo. No ha realizado actividades ejercicios mental entregadas por mi. Manifiesta inter=C3=A9s por una lectura sugeridas. Mantiene escasa ingesta de l=C3=ADquidos (agua o jugos) en total 200cc. Solo consumo de Cafe (varias tazas al dia. Desea realizar actividad fisica y muestra interes. Hija intentar=C3=A1 conseguir KNT motora de forma particular.</div>
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Examen F=C3=ADsico<label for=3D"m_-8845590695791215203itemView.getDomIdToLabel()">
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Posici=C3=B3n y dec=C3=BAbito: en sedestaci=C3=B3n durante la entrevista y examen.=20Marcha y deambulaci=C3=B3n: deambular pero con dificultad y lentitud sin ayuda de bast=C3=B3n.=20Examen mental: consciente, orientado en espacio, necesita ayuda para orientarse en tiempo y los d=C3=ADas. Escala de Glasgow 15 puntos.=20Lenguaje: sin alteraci=C3=B3n=20Constituci=C3=B3n y estado nutritivo: bajo peso=20Piel y anexos: Color: uniforme rosada, tibia y seca al tacto, intacta, reviso e inspecciono ausencia de lesiones; turgor y elasticidad propias de la edad. Mucosas hidratadas.=20Pelo y u=C3=B1as: sin alteraciones, u=C3=B1as en manejo por pod=C3=B3logo==20Control de signos vitales: PA: 98/86 mmHg hipotenso asintom=C3=A1tico, FC: 76x` eucardico, ritmo regular, sin dolor oncol=C3=B3gico referido. Auscultaci=C3=B3n MP (+) sin ruidos agregados. Sat 92% Temp: 35.2=C2=B0C=20Extremidades superiores: sin alteraciones, manos fr=C3=ADas.=20Extremidades inferiores indemnes a la inspecci=C3=B3n, fuerza y movilidad disminuida propia de la edad. Persiste el edema (+++) sin manejo con calcetas compresivas (antiguas). Pies fr=C3=ADos, Pulso pedio (++)Genital: referido, mantiene uso de pa=C3=B1ales, sin hematuria, seg=C3=BAn refiere su cantidad de orina es variable en el d=C3=ADa.=20Descanso: sue=C3=B1o reparador a vece mayor de 10hrs, periodo de la siesta 2 a 3hrs post almuerzo.=20Alimentaci=C3=B3n: escaso consumo de agua, consume 3 comidas importantes/ d=C3=ADa. Higiene: muy buena.</div>
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Diagn=C3=B3stico<label for=3D"m_-8845590695791215203itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8845590695791215203ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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Ca de Pr=C3=B3stata</div>
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Plan de Tratamiento e Indicaciones<label for=3D"m_-8845590695791215203itemView.getDomIdToLabel()">
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Realizar idealmente sesiones de Kine motora (Rechazado)=20Realizar lectura de inter=C3=A9s, que impliquen fechas e hitos.=20Realizar ejercicios de act. mental como SODOKU - sopa de letras (de su inter=C3=A9s) Mantener radio y calendarios a mano=20Avisar en caso de sangrado en orina=20Se insiste en utilizar medias de compresion (nuevas) grado 70</div>
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Medicamentos Indicados</div>
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Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_-8845590695791215203ss-q-help m_-8845590695791215203ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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Month</option>
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January</option>
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7</option>
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10</option>
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11</option>
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19</option>
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21</option>
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22</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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31</option>
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1896</option>
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1899</option>
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1900</option>
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1901</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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1910</option>
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1911</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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1932</option>
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1933</option>
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1935</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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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>
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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>
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2051</option>
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2052</option>
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2053</option>
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2054</option>
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2055</option>
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2056</option>
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2057</option>
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2058</option>
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2059</option>
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2060</option>
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2061</option>
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2062</option>
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2063</option>
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2064</option>
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2065</option>
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2066</option>
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2067</option>
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2068</option>
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2069</option>
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</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8845590695791215203ss-form-question m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-text" style=3D"margin:12px 0">
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<label class=3D"m_-8845590695791215203ss-q-item-label" for=3D"m_-8845590695791215203entry_74766472">
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Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_-8845590695791215203ss-q-help m_-8845590695791215203ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8845590695791215203ss-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>
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Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_-8845590695791215203ss-q-help m_-8845590695791215203ss-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_-8845590695791215203ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
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</span>
<span class=3D"m_-8845590695791215203ss-choice-label">
ENFERMERA</span>
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<label>
<span class=3D"m_-8845590695791215203ss-choice-item-control m_-8845590695791215203goog-inline-block" style=3D"display:inline-block">
<input name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_-8845590695791215203group_503039759_2" class=3D"m_-8845590695791215203ss-q-checkbox" type=3D"checkbox">
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<span class=3D"m_-8845590695791215203ss-choice-label">
TENS</span>
</label>
</li>
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<label>
<span class=3D"m_-8845590695791215203ss-choice-item-control m_-8845590695791215203goog-inline-block" style=3D"display:inline-block">
<input name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id=3D"m_-8845590695791215203group_503039759_3" class=3D"m_-8845590695791215203ss-q-checkbox" type=3D"checkbox">
</span>
<span class=3D"m_-8845590695791215203ss-choice-label">
NUTRICIONISTA</span>
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<label>
<span class=3D"m_-8845590695791215203ss-choice-item-control m_-8845590695791215203goog-inline-block" style=3D"display:inline-block">
<input name=3D"entry.503039759" disabled value=3D"KINESIOLOGO" id=3D"m_-8845590695791215203group_503039759_4" class=3D"m_-8845590695791215203ss-q-checkbox" type==3D"checkbox">
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<span class=3D"m_-8845590695791215203ss-choice-label">
KINESIOLOGO</span>
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<span class=3D"m_-8845590695791215203ss-choice-item-control m_-8845590695791215203goog-inline-block" style=3D"display:inline-block">
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<span class=3D"m_-8845590695791215203ss-choice-label">
PSICOLOGO</span>
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</div>
<br>
 <div class=3D"m_-8845590695791215203errorbox-good">
<div dir=3D"auto" class=3D"m_-8845590695791215203ss-item m_-8845590695791215203ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-8845590695791215203ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8845590695791215203ss-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_-8845590695791215203ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
</form>
</div>
</div>
</td>
</tr>
<tr height=3D"24px">
</tr>
</tbody>
</table>
</div>
<table style=3D"max-width:672px;min-width:154px" align=3D"center" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242;font-size:13px" target=3D"_blank">
Create your own Google Form</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br clear=3D"all">
<br>
-- <br>
<div dir=3D"ltr" class=3D"gmail_signature" data-smartmail=3D"gmail_signature">
<div dir=3D"ltr">
M=C2=AA Esperanza Oyarz=C3=BAn S.<br>
Cel: 78879565<br>
</div>
</div>
</div>
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