<html>

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<br>

<br>

<div id="AppleMailSignature" dir="ltr">
Enviado desde mi iPhone</div>

<div dir="ltr">
<br>

Inicio del mensaje reenviado:<br>

<br>

</div>

<blockquote type="cite">

<div dir="ltr">
<b>
De:</b>
 Formularios de Google &lt;<a href="mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;<br>

<b>
Fecha:</b>
 10 de junio de 2019, 9:45:24 p. m. GMT-4<br>

<b>
Para:</b>
 <a href="mailto:katiusca-8@hotmail.com">
katiusca-8@hotmail.com</a>
<br>

<b>
Asunto:</b>
 <b>
Registro de Atención Domiciliaria Oncovida</b>
<br>

<br>

</div>

</blockquote>

<blockquote type="cite">

<div dir="ltr">

<table border="0" cellpadding="0" cellspacing="0" style="background-color:rgb(38,4,154);" width="100%" role="presentation">

<tbody>

<tr height="64px">

<td style="padding-left: 24px">
<img alt="Formularios de Google" height="26px" style="display: inline-block; margin: 0; vertical-align: middle;" width="143px" src="https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>

</tr>

</tbody>

</table>

<div style="padding: 24px; background-color:rgb(229,218,254)">

<div align="center" style="background-color: #fff; border-bottom: 1px solid #e0e0e0; margin: 0 auto; max-width: 624px; min-width: 154px; padding: 0 24px;">

<table align="center" cellpadding="0" cellspacing="0" style="background-color: #fff;" width="100%" role="presentation">

<tbody>

<tr height="24px">

<td>
</td>

</tr>

<tr>

<td>

<div style="font-size: 13px; line-height: 18px; color: #424242; font-weight: 700">

Gracias por rellenar <a href="https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=mail_form_link">

Registro de Atención Domiciliaria Oncovida</a>
</div>

</td>

</tr>

<tr height="12px">

</tr>

<tr>

<td>

<div style="font-size: 13px; line-height: 18px; color: #424242;">
Esto es lo que nos has enviado:</div>

</td>

</tr>

<tr>

<td>

<div class="ss-form-container" style="">

<div class="ss-form-heading" style="">

<h1 class="ss-form-title" dir="ltr" style="margin:.67em 0;">
Registro de Atención Domiciliaria Oncovida</h1>

<div class="ss-form-desc ss-no-ignore-whitespace" style="font:inherit;width:99%;margin:0 0 1em;white-space:pre-wrap;word-wrap:break-word;">

Este es el sistema de registro de atenciones domiciliarias de Oncovida. Debe ser llenado por el prestador individual, y debe realizarse un registro por cada visita domiciliaria. Si usted no es prestador de Oncovida por favor no llene este formulario. A continuación
 indique su correo electrónico.</div>

</div>

<div class="ss-form" style="">

<form action="" method="GET" id="ss-form" style="">
<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">

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

<label class="ss-q-item-label" for="emailAddress" style="">

<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

Dirección de correo electrónico <label for="emailAddress" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

</label>

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

<a href="mailto:katiusca-8@hotmail.com">
katiusca-8@hotmail.com</a>
</div>

</div>

</div>

</div>

<div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-embeddable-object-container" style="margin:12px 0;max-width:100%;position:relative;">

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

<h2 class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

</h2>

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

</div>

</div>

</div>

<br>

<div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-page-break" style="margin:12px 0;">

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

<h2 class="ss-page-title" style="margin:2em -0.4em 0;padding:0.4em;background-color:#eee;">

Identificación del Prestador</h2>

<div class="ss-page-description ss-no-ignore-whitespace" dir="auto" style="white-space:pre-wrap;word-wrap:break-word;">

Aquí debe ingresar sus datos personales</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">

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

<label class="ss-q-item-label" for="entry_579114469" style="">

<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

Primer Nombre y Apellido Paterno <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">

</div>

</label>

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

Karen Mercado </div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">

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

<label class="ss-q-item-label" for="entry_1276273985" style="">

<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

RUT <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">

RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>

</label>

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

26718432-1</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-select" style="margin:12px 0;">

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

<label class="ss-q-item-label" for="entry_133691676" style="">

<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

Tipo <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">

Si asisten más de 1 prestador simultáneamente, cada uno debe hacer un registro independiente</div>

</label>
<select name="entry.133691676" disabled="" id="entry_133691676" aria-label="Tipo Si asisten más de 1 prestador simultáneamente, cada uno debe hacer un registro independiente " aria-required="true" style="">
<option value="" style="">

</option>
 <option value="MEDICO" disabled="" selected="" style="">
MEDICO</option>

<option value="ENFERMERA/O" disabled="" style="">
ENFERMERA/O</option>
 <option value="TENS" disabled="" style="">

TENS</option>
 <option value="KINESIOLOGA/O" disabled="" style="">
KINESIOLOGA/O</option>

<option value="PSICOLOGO" disabled="" style="">
PSICOLOGO</option>
 <option value="NUTRICIONISTA" disabled="" style="">

NUTRICIONISTA</option>
</select>
 </div>

</div>

</div>

<br>

<div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-embeddable-object-container" style="margin:12px 0;max-width:100%;position:relative;">

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

<h2 class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

</h2>

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

</div>

</div>

</div>

<br>

<div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-page-break" style="margin:12px 0;">

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

<h2 class="ss-page-title" style="margin:2em -0.4em 0;padding:0.4em;background-color:#eee;">

Identificación del Paciente</h2>

<div class="ss-page-description ss-no-ignore-whitespace" dir="auto" style="white-space:pre-wrap;word-wrap:break-word;">

En esta sección debe ingresar los datos del paciente visitado</div>

</div>

</div>

</div>

<br>

<div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-section-header" style="margin:12px 0;">

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

<h2 class="ss-section-title" style="background-color:#eee;padding:0.4em;margin:2em -0.4em 0;">

Datos Personales del Paciente</h2>

<div class="ss-section-description ss-no-ignore-whitespace" style="margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word;">

</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">

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

<label class="ss-q-item-label" for="entry_823811303" style="">

<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

Ingrese el Rut del Paciente <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">

RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>

</label>

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

4313687-9</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">

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

<label class="ss-q-item-label" for="entry_1959365839" style="">

<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

Ingrese el Primer Nombre y Apellido Paterno del Paciente <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">

</div>

</label>

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

Selfa Antiman</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-select" style="margin:12px 0;">

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

<label class="ss-q-item-label" for="entry_545002227" style="">

<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

Previsión <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">

</div>

</label>
<select name="entry.545002227" disabled="" id="entry_545002227" aria-label="Previsión  " aria-required="true" style="">
<option value="" style="">

</option>
 <option value="BANMEDICA" disabled="" style="">
BANMEDICA</option>
 <option value="CAPREDENA" disabled="" style="">

CAPREDENA</option>
 <option value="COLMENA" disabled="" style="">
COLMENA</option>
 <option value="CONSALUD" disabled="" style="">

CONSALUD</option>
 <option value="CRUZ BLANCA" disabled="" style="">
CRUZ BLANCA</option>

<option value="DIPRECA" disabled="" selected="" style="">
DIPRECA</option>
 <option value="FONASA" disabled="" style="">

FONASA</option>
 <option value="FUNDACION" disabled="" style="">
FUNDACION</option>

<option value="ISAPRES DEL COBRE" disabled="" style="">
ISAPRES DEL COBRE</option>

<option value="NUEVA MASVIDA" disabled="" style="">
NUEVA MASVIDA</option>
 <option value="VIDATRES" disabled="" style="">

VIDATRES</option>
 <option value="PARTICULAR" disabled="" style="">
PARTICULAR</option>
</select>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">

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

<label class="ss-q-item-label" for="entry_1900161356" style="">

<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

Ciudad <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">

</div>

</label>

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

San Felipe </div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">

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

<label class="ss-q-item-label" for="entry_1298871758" style="">

<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

Comuna <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">

</div>

</label>

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

Santa María </div>

</div>

</div>

</div>

<br>

<div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-embeddable-object-container" style="margin:12px 0;max-width:100%;position:relative;">

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

<h2 class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

</h2>

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

</div>

</div>

</div>

<br>

<div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-page-break" style="margin:12px 0;">

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

<h2 class="ss-page-title" style="margin:2em -0.4em 0;padding:0.4em;background-color:#eee;">

Registro de la Atención Domiciliaria</h2>

<div class="ss-page-description ss-no-ignore-whitespace" dir="auto" style="white-space:pre-wrap;word-wrap:break-word;">

En esta sección debe ingresar los datos de la atención domiciliaria</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-radio" style="margin:12px 0;">

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

<label class="ss-q-item-label" for="entry_2073233714" style="">

<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

Tipo de Atención <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">

</div>

</label>

<ul class="ss-choices" role="radiogroup" aria-label="Tipo de Atención  " style="list-style:none;padding:0;margin:.5em 0 0;">

<li class="ss-choice-item" style="margin:0;line-height:1.3em;padding-bottom:.5em;">

<label>
<span class="ss-choice-item-control goog-inline-block" style="position:relative;display:inline-block;">
<input type="radio" name="entry.1222378237" disabled="" checked="" value="Domicilio" id="group_1222378237_1" role="radio" class="ss-q-radio" aria-label="Domicilio" aria-required="true" style="">
</span>

<span class="ss-choice-label" style="">
Domicilio</span>
 </label>
</li>
<li class="ss-choice-item" style="margin:0;line-height:1.3em;padding-bottom:.5em;">

<label>
<span class="ss-choice-item-control goog-inline-block" style="position:relative;display:inline-block;">
<input type="radio" name="entry.1222378237" disabled="" value="Ambulatorio" id="group_1222378237_2" role="radio" class="ss-q-radio" aria-label="Ambulatorio" aria-required="true" style="">
</span>

<span class="ss-choice-label" style="">
Ambulatorio</span>
 </label>
</li>
</ul>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-date" style="margin:12px 0;">

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

<label class="ss-q-item-label" for="entry_1705849412" style="">

<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

Fecha de la Atención <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">

</div>

</label>

<div class="ss-q-date" role="group" aria-label="Fecha de la Atención  " style="">

<div class="ss-datetime-box goog-inline-block" role="group" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;position:relative;display:inline-block;">

<select name="entry.1705849412_day" disabled="" class="ss-day-dropdown" id="entry.1705849412_day" aria-label="Día del mes" aria-required="true" style="">
<option value="" style="">

Día</option>
 <option value="1" style="">
1</option>
 <option value="2" style="">
2</option>

<option value="3" style="">
3</option>
 <option value="4" style="">
4</option>
 <option value="5" style="">

5</option>
 <option value="6" style="">
6</option>
 <option value="7" style="">
7</option>

<option value="8" style="">
8</option>
 <option value="9" style="">
9</option>
 <option value="10" selected="" style="">

10</option>
 <option value="11" style="">
11</option>
 <option value="12" style="">
12
</option>
 <option value="13" style="">
13</option>
 <option value="14" style="">
14</option>

<option value="15" style="">
15</option>
 <option value="16" style="">
16</option>
 <option value="17" style="">

17</option>
 <option value="18" style="">
18</option>
 <option value="19" style="">
19
</option>
 <option value="20" style="">
20</option>
 <option value="21" style="">
21</option>

<option value="22" style="">
22</option>
 <option value="23" style="">
23</option>
 <option value="24" style="">

24</option>
 <option value="25" style="">
25</option>
 <option value="26" style="">
26
</option>
 <option value="27" style="">
27</option>
 <option value="28" style="">
28</option>

<option value="29" style="">
29</option>
 <option value="30" style="">
30</option>
 <option value="31" style="">

31</option>
</select>
 <select name="entry.1705849412_month" disabled="" class="ss-month-dropdown" id="entry.1705849412_month" aria-label="Mes" aria-required="true" style="">
<option value="" style="">

Mes</option>
 <option value="1" style="">
enero</option>
 <option value="2" style="">

febrero</option>
 <option value="3" style="">
marzo</option>
 <option value="4" style="">

abril</option>
 <option value="5" style="">
mayo</option>
 <option value="6" selected="" style="">

junio</option>
 <option value="7" style="">
julio</option>
 <option value="8" style="">

agosto</option>
 <option value="9" style="">
septiembre</option>
 <option value="10" style="">

octubre</option>
 <option value="11" style="">
noviembre</option>
 <option value="12" style="">

diciembre</option>
</select>
 <select name="entry.1705849412_year" disabled="" id="entry.1705849412_year" aria-label="Año" aria-required="true" style="">
<option value="" style="">

Año</option>
 <option value="1896" style="">
1896</option>
 <option value="1897" style="">

1897</option>
 <option value="1898" style="">
1898</option>
 <option value="1899" style="">

1899</option>
 <option value="1900" style="">
1900</option>
 <option value="1901" style="">

1901</option>
 <option value="1902" style="">
1902</option>
 <option value="1903" style="">

1903</option>
 <option value="1904" style="">
1904</option>
 <option value="1905" style="">

1905</option>
 <option value="1906" style="">
1906</option>
 <option value="1907" style="">

1907</option>
 <option value="1908" style="">
1908</option>
 <option value="1909" style="">

1909</option>
 <option value="1910" style="">
1910</option>
 <option value="1911" style="">

1911</option>
 <option value="1912" style="">
1912</option>
 <option value="1913" style="">

1913</option>
 <option value="1914" style="">
1914</option>
 <option value="1915" style="">

1915</option>
 <option value="1916" style="">
1916</option>
 <option value="1917" style="">

1917</option>
 <option value="1918" style="">
1918</option>
 <option value="1919" style="">

1919</option>
 <option value="1920" style="">
1920</option>
 <option value="1921" style="">

1921</option>
 <option value="1922" style="">
1922</option>
 <option value="1923" style="">

1923</option>
 <option value="1924" style="">
1924</option>
 <option value="1925" style="">

1925</option>
 <option value="1926" style="">
1926</option>
 <option value="1927" style="">

1927</option>
 <option value="1928" style="">
1928</option>
 <option value="1929" style="">

1929</option>
 <option value="1930" style="">
1930</option>
 <option value="1931" style="">

1931</option>
 <option value="1932" style="">
1932</option>
 <option value="1933" style="">

1933</option>
 <option value="1934" style="">
1934</option>
 <option value="1935" style="">

1935</option>
 <option value="1936" style="">
1936</option>
 <option value="1937" style="">

1937</option>
 <option value="1938" style="">
1938</option>
 <option value="1939" style="">

1939</option>
 <option value="1940" style="">
1940</option>
 <option value="1941" style="">

1941</option>
 <option value="1942" style="">
1942</option>
 <option value="1943" style="">

1943</option>
 <option value="1944" style="">
1944</option>
 <option value="1945" style="">

1945</option>
 <option value="1946" style="">
1946</option>
 <option value="1947" style="">

1947</option>
 <option value="1948" style="">
1948</option>
 <option value="1949" style="">

1949</option>
 <option value="1950" style="">
1950</option>
 <option value="1951" style="">

1951</option>
 <option value="1952" style="">
1952</option>
 <option value="1953" style="">

1953</option>
 <option value="1954" style="">
1954</option>
 <option value="1955" style="">

1955</option>
 <option value="1956" style="">
1956</option>
 <option value="1957" style="">

1957</option>
 <option value="1958" style="">
1958</option>
 <option value="1959" style="">

1959</option>
 <option value="1960" style="">
1960</option>
 <option value="1961" style="">

1961</option>
 <option value="1962" style="">
1962</option>
 <option value="1963" style="">

1963</option>
 <option value="1964" style="">
1964</option>
 <option value="1965" style="">

1965</option>
 <option value="1966" style="">
1966</option>
 <option value="1967" style="">

1967</option>
 <option value="1968" style="">
1968</option>
 <option value="1969" style="">

1969</option>
 <option value="1970" style="">
1970</option>
 <option value="1971" style="">

1971</option>
 <option value="1972" style="">
1972</option>
 <option value="1973" style="">

1973</option>
 <option value="1974" style="">
1974</option>
 <option value="1975" style="">

1975</option>
 <option value="1976" style="">
1976</option>
 <option value="1977" style="">

1977</option>
 <option value="1978" style="">
1978</option>
 <option value="1979" style="">

1979</option>
 <option value="1980" style="">
1980</option>
 <option value="1981" style="">

1981</option>
 <option value="1982" style="">
1982</option>
 <option value="1983" style="">

1983</option>
 <option value="1984" style="">
1984</option>
 <option value="1985" style="">

1985</option>
 <option value="1986" style="">
1986</option>
 <option value="1987" style="">

1987</option>
 <option value="1988" style="">
1988</option>
 <option value="1989" style="">

1989</option>
 <option value="1990" style="">
1990</option>
 <option value="1991" style="">

1991</option>
 <option value="1992" style="">
1992</option>
 <option value="1993" style="">

1993</option>
 <option value="1994" style="">
1994</option>
 <option value="1995" style="">

1995</option>
 <option value="1996" style="">
1996</option>
 <option value="1997" style="">

1997</option>
 <option value="1998" style="">
1998</option>
 <option value="1999" style="">

1999</option>
 <option value="2000" style="">
2000</option>
 <option value="2001" style="">

2001</option>
 <option value="2002" style="">
2002</option>
 <option value="2003" style="">

2003</option>
 <option value="2004" style="">
2004</option>
 <option value="2005" style="">

2005</option>
 <option value="2006" style="">
2006</option>
 <option value="2007" style="">

2007</option>
 <option value="2008" style="">
2008</option>
 <option value="2009" style="">

2009</option>
 <option value="2010" style="">
2010</option>
 <option value="2011" style="">

2011</option>
 <option value="2012" style="">
2012</option>
 <option value="2013" style="">

2013</option>
 <option value="2014" style="">
2014</option>
 <option value="2015" style="">

2015</option>
 <option value="2016" style="">
2016</option>
 <option value="2017" style="">

2017</option>
 <option value="2018" style="">
2018</option>
 <option value="2019" selected="" style="">

2019</option>
 <option value="2020" style="">
2020</option>
 <option value="2021" style="">

2021</option>
 <option value="2022" style="">
2022</option>
 <option value="2023" style="">

2023</option>
 <option value="2024" style="">
2024</option>
 <option value="2025" style="">

2025</option>
 <option value="2026" style="">
2026</option>
 <option value="2027" style="">

2027</option>
 <option value="2028" style="">
2028</option>
 <option value="2029" style="">

2029</option>
 <option value="2030" style="">
2030</option>
 <option value="2031" style="">

2031</option>
 <option value="2032" style="">
2032</option>
 <option value="2033" style="">

2033</option>
 <option value="2034" style="">
2034</option>
 <option value="2035" style="">

2035</option>
 <option value="2036" style="">
2036</option>
 <option value="2037" style="">

2037</option>
 <option value="2038" style="">
2038</option>
 <option value="2039" style="">

2039</option>
 <option value="2040" style="">
2040</option>
 <option value="2041" style="">

2041</option>
 <option value="2042" style="">
2042</option>
 <option value="2043" style="">

2043</option>
 <option value="2044" style="">
2044</option>
 <option value="2045" style="">

2045</option>
 <option value="2046" style="">
2046</option>
 <option value="2047" style="">

2047</option>
 <option value="2048" style="">
2048</option>
 <option value="2049" style="">

2049</option>
 <option value="2050" style="">
2050</option>
 <option value="2051" style="">

2051</option>
 <option value="2052" style="">
2052</option>
 <option value="2053" style="">

2053</option>
 <option value="2054" style="">
2054</option>
 <option value="2055" style="">

2055</option>
 <option value="2056" style="">
2056</option>
 <option value="2057" style="">

2057</option>
 <option value="2058" style="">
2058</option>
 <option value="2059" style="">

2059</option>
 <option value="2060" style="">
2060</option>
 <option value="2061" style="">

2061</option>
 <option value="2062" style="">
2062</option>
 <option value="2063" style="">

2063</option>
 <option value="2064" style="">
2064</option>
 <option value="2065" style="">

2065</option>
 <option value="2066" style="">
2066</option>
 <option value="2067" style="">

2067</option>
 <option value="2068" style="">
2068</option>
 <option value="2069" style="">

2069</option>
</select>
 </div>

</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-time" style="margin:12px 0;font:inherit;">

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

<label class="ss-q-item-label" for="entry_206244955" style="">

<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

Hora de la Atención <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">

</div>

</label>

<div class="ss-q-time" style="">

<div class="ss-datetime-box goog-inline-block" dir="ltr" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;position:relative;display:inline-block;">

<select name="entry.206244955_hour" disabled="" id="entry.206244955_hour" aria-label="Hora" aria-required="true" style="">
<option value="" style="">

h</option>
 <option value="00" style="">
00</option>
 <option value="01" style="">
01
</option>
 <option value="02" style="">
02</option>
 <option value="03" style="">
03</option>

<option value="04" style="">
04</option>
 <option value="05" style="">
05</option>
 <option value="06" style="">

06</option>
 <option value="07" style="">
07</option>
 <option value="08" style="">
08
</option>
 <option value="09" style="">
09</option>
 <option value="10" style="">
10</option>

<option value="11" selected="" style="">
11</option>
 <option value="12" style="">
12
</option>
 <option value="13" style="">
13</option>
 <option value="14" style="">
14</option>

<option value="15" style="">
15</option>
 <option value="16" style="">
16</option>
 <option value="17" style="">

17</option>
 <option value="18" style="">
18</option>
 <option value="19" style="">
19
</option>
 <option value="20" style="">
20</option>
 <option value="21" style="">
21</option>

<option value="22" style="">
22</option>
 <option value="23" style="">
23</option>
</select>
 :
<select name="entry.206244955_minute" disabled="" id="entry.206244955_minute" aria-label="Minuto" aria-required="true" style="">
<option value="" style="">

min</option>
 <option value="00" style="">
00</option>
 <option value="01" style="">

01</option>
 <option value="02" style="">
02</option>
 <option value="03" style="">
03
</option>
 <option value="04" style="">
04</option>
 <option value="05" style="">
05</option>

<option value="06" style="">
06</option>
 <option value="07" style="">
07</option>
 <option value="08" style="">

08</option>
 <option value="09" style="">
09</option>
 <option value="10" style="">
10
</option>
 <option value="11" style="">
11</option>
 <option value="12" style="">
12</option>

<option value="13" style="">
13</option>
 <option value="14" style="">
14</option>
 <option value="15" style="">

15</option>
 <option value="16" style="">
16</option>
 <option value="17" style="">
17
</option>
 <option value="18" style="">
18</option>
 <option value="19" style="">
19</option>

<option value="20" selected="" style="">
20</option>
 <option value="21" style="">
21
</option>
 <option value="22" style="">
22</option>
 <option value="23" style="">
23</option>

<option value="24" style="">
24</option>
 <option value="25" style="">
25</option>
 <option value="26" style="">

26</option>
 <option value="27" style="">
27</option>
 <option value="28" style="">
28
</option>
 <option value="29" style="">
29</option>
 <option value="30" style="">
30</option>

<option value="31" style="">
31</option>
 <option value="32" style="">
32</option>
 <option value="33" style="">

33</option>
 <option value="34" style="">
34</option>
 <option value="35" style="">
35
</option>
 <option value="36" style="">
36</option>
 <option value="37" style="">
37</option>

<option value="38" style="">
38</option>
 <option value="39" style="">
39</option>
 <option value="40" style="">

40</option>
 <option value="41" style="">
41</option>
 <option value="42" style="">
42
</option>
 <option value="43" style="">
43</option>
 <option value="44" style="">
44</option>

<option value="45" style="">
45</option>
 <option value="46" style="">
46</option>
 <option value="47" style="">

47</option>
 <option value="48" style="">
48</option>
 <option value="49" style="">
49
</option>
 <option value="50" style="">
50</option>
 <option value="51" style="">
51</option>

<option value="52" style="">
52</option>
 <option value="53" style="">
53</option>
 <option value="54" style="">

54</option>
 <option value="55" style="">
55</option>
 <option value="56" style="">
56
</option>
 <option value="57" style="">
57</option>
 <option value="58" style="">
58</option>

<option value="59" style="">
59</option>
</select>

<div class="ss-datetime-box-spacer goog-inline-block" style="height:32px;vertical-align:middle;position:relative;display:inline-block;">

</div>

</div>

</div>

</div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-select" style="margin:12px 0;">

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

<label class="ss-q-item-label" for="entry_1747608258" style="">

<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

Performance Status ECOG del Paciente <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

</label>
<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">

</div>

</label>
<select name="entry.1747608258" disabled="" id="entry_1747608258" aria-label="Performance Status ECOG del Paciente  " aria-required="true" style="">
<option value="" style="">

</option>
 <option value="0" disabled="" style="">
0</option>
 <option value="1" disabled="" style="">

1</option>
 <option value="2" disabled="" selected="" style="">
2</option>
 <option value="3" disabled="" style="">

3</option>
 <option value="4" disabled="" style="">
4</option>
</select>
 </div>

</div>

</div>

<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-scale" style="margin:12px 0;overflow-x:auto;">

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

<label class="ss-q-item-label" for="entry_1716090865" style="">

<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">

Escala Dolor EVA Actual </div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">

</div>

</label>

<table border="0" cellpadding="5" cellspacing="0" id="entry_1421689035" style="">

<tbody>

<tr aria-hidden="true" style="">

<td class="ss-scalenumbers" style="text-align:center;">
</td>

<td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_1" style="display:block;padding:0.5em 0 .5em;">
0</label>
</td>

<td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_2" style="display:block;padding:0.5em 0 .5em;">
1</label>
</td>

<td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_3" style="display:block;padding:0.5em 0 .5em;">
2</label>
</td>

<td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_4" style="display:block;padding:0.5em 0 .5em;">
3</label>
</td>

<td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_5" style="display:block;padding:0.5em 0 .5em;">
4</label>
</td>

<td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_6" style="display:block;padding:0.5em 0 .5em;">
5</label>
</td>

<td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_7" style="display:block;padding:0.5em 0 .5em;">
6</label>
</td>

<td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_8" style="display:block;padding:0.5em 0 .5em;">
7</label>
</td>

<td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_9" style="display:block;padding:0.5em 0 .5em;">
8</label>
</td>

<td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_10" style="display:block;padding:0.5em 0 .5em;">
9</label>
</td>

<td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_11" style="display:block;padding:0.5em 0 .5em;">
10</label>
</td>

<td class="ss-scalenumbers" style="text-align:center;">
</td>

</tr>

<tr role="radiogroup" aria-label="Escala Dolor EVA Actual  Selecciona un valor en el intervalo de 0 a 10 ." style="">

<td class="ss-scalerow ss-leftlabel" style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0;">

<div aria-hidden="true" class="aria-todo" style="">
</div>

</td>

<td class="ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">

<div class="ss-scalerow-fieldcell" style="">
<input type="radio" name="entry.1421689035" disabled="" checked="" value="0" id="group_1421689035_1" role="radio" class="ss-q-radio" aria-label="0" style="">
</div>

</td>

<td class="ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">

<div class="ss-scalerow-fieldcell" style="">
<input type="radio" name="entry.1421689035" disabled="" value="1" id="group_1421689035_2" role="radio" class="ss-q-radio" aria-label="1" style="">
</div>

</td>

<td class="ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">

<div class="ss-scalerow-fieldcell" style="">
<input type="radio" name="entry.1421689035" disabled="" value="2" id="group_1421689035_3" role="radio" class="ss-q-radio" aria-label="2" style="">
</div>

</td>

<td class="ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">

<div class="ss-scalerow-fieldcell" style="">
<input type="radio" name="entry.1421689035" disabled="" value="3" id="group_1421689035_4" role="radio" class="ss-q-radio" aria-label="3" style="">
</div>

</td>

<td class="ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">

<div class="ss-scalerow-fieldcell" style="">
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Escala Dolor EVA Máximo </div>

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Paciente en regulares condiciones, con alteración para conciliar el sueño, vomitos ocasionales, cefalea. Refiere aumento de cifras tensiónales
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Escleras con buena coloración. Ruidos cardiacos rítmicos, sin soplos. Pulmones claros, ventilados, no agregados. Abdomen con masa palpable en hemiabdomen superior dolorosa a la palpación, no irritación peritoneal, no distensión. Extremidades Sin edemas.
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Cancer Gástrico </div>

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Plan de Tratamiento e Indicaciones <label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">

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Se aumenta dosis de Losartan Se agrega Alprazolam comp 0,25 día y Tramal gotas SOS Dieta baja en grasas, sin condimento
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Medicamentos Indicados </div>

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Tratamiento Paliativo </div>

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Fecha aproximada del Próximo Control con usted </div>

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<div class="ss-datetime-box goog-inline-block" role="group" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;position:relative;display:inline-block;">

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Día</option>
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1</option>
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2</option>

<option value="3" style="">
3</option>
 <option value="4" style="">
4</option>
 <option value="5" style="">

5</option>
 <option value="6" style="">
6</option>
 <option value="7" style="">
7</option>

<option value="8" style="">
8</option>
 <option value="9" style="">
9</option>
 <option value="10" style="">

10</option>
 <option value="11" style="">
11</option>
 <option value="12" style="">
12
</option>
 <option value="13" style="">
13</option>
 <option value="14" style="">
14</option>

<option value="15" style="">
15</option>
 <option value="16" style="">
16</option>
 <option value="17" style="">

17</option>
 <option value="18" style="">
18</option>
 <option value="19" style="">
19
</option>
 <option value="20" style="">
20</option>
 <option value="21" style="">
21</option>

<option value="22" selected="" style="">
22</option>
 <option value="23" style="">
23
</option>
 <option value="24" style="">
24</option>
 <option value="25" style="">
25</option>

<option value="26" style="">
26</option>
 <option value="27" style="">
27</option>
 <option value="28" style="">

28</option>
 <option value="29" style="">
29</option>
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30
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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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septiembre</option>
 <option value="10" style="">

octubre</option>
 <option value="11" style="">
noviembre</option>
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diciembre</option>
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<option value="" style="">

Año</option>
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1896</option>
 <option value="1897" style="">

1897</option>
 <option value="1898" style="">
1898</option>
 <option value="1899" style="">

1899</option>
 <option value="1900" style="">
1900</option>
 <option value="1901" style="">

1901</option>
 <option value="1902" style="">
1902</option>
 <option value="1903" style="">

1903</option>
 <option value="1904" style="">
1904</option>
 <option value="1905" style="">

1905</option>
 <option value="1906" style="">
1906</option>
 <option value="1907" style="">

1907</option>
 <option value="1908" style="">
1908</option>
 <option value="1909" style="">

1909</option>
 <option value="1910" style="">
1910</option>
 <option value="1911" style="">

1911</option>
 <option value="1912" style="">
1912</option>
 <option value="1913" style="">

1913</option>
 <option value="1914" style="">
1914</option>
 <option value="1915" style="">

1915</option>
 <option value="1916" style="">
1916</option>
 <option value="1917" style="">

1917</option>
 <option value="1918" style="">
1918</option>
 <option value="1919" style="">

1919</option>
 <option value="1920" style="">
1920</option>
 <option value="1921" style="">

1921</option>
 <option value="1922" style="">
1922</option>
 <option value="1923" style="">

1923</option>
 <option value="1924" style="">
1924</option>
 <option value="1925" style="">

1925</option>
 <option value="1926" style="">
1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
 <option value="1935" style="">

1935</option>
 <option value="1936" style="">
1936</option>
 <option value="1937" style="">

1937</option>
 <option value="1938" style="">
1938</option>
 <option value="1939" style="">

1939</option>
 <option value="1940" style="">
1940</option>
 <option value="1941" style="">

1941</option>
 <option value="1942" style="">
1942</option>
 <option value="1943" style="">

1943</option>
 <option value="1944" style="">
1944</option>
 <option value="1945" style="">

1945</option>
 <option value="1946" style="">
1946</option>
 <option value="1947" style="">

1947</option>
 <option value="1948" style="">
1948</option>
 <option value="1949" style="">

1949</option>
 <option value="1950" style="">
1950</option>
 <option value="1951" style="">

1951</option>
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1952</option>
 <option value="1953" style="">

1953</option>
 <option value="1954" style="">
1954</option>
 <option value="1955" style="">

1955</option>
 <option value="1956" style="">
1956</option>
 <option value="1957" style="">

1957</option>
 <option value="1958" style="">
1958</option>
 <option value="1959" style="">

1959</option>
 <option value="1960" style="">
1960</option>
 <option value="1961" style="">

1961</option>
 <option value="1962" style="">
1962</option>
 <option value="1963" style="">

1963</option>
 <option value="1964" style="">
1964</option>
 <option value="1965" style="">

1965</option>
 <option value="1966" style="">
1966</option>
 <option value="1967" style="">

1967</option>
 <option value="1968" style="">
1968</option>
 <option value="1969" style="">

1969</option>
 <option value="1970" style="">
1970</option>
 <option value="1971" style="">

1971</option>
 <option value="1972" style="">
1972</option>
 <option value="1973" style="">

1973</option>
 <option value="1974" style="">
1974</option>
 <option value="1975" style="">

1975</option>
 <option value="1976" style="">
1976</option>
 <option value="1977" style="">

1977</option>
 <option value="1978" style="">
1978</option>
 <option value="1979" style="">

1979</option>
 <option value="1980" style="">
1980</option>
 <option value="1981" style="">

1981</option>
 <option value="1982" style="">
1982</option>
 <option value="1983" style="">

1983</option>
 <option value="1984" style="">
1984</option>
 <option value="1985" style="">

1985</option>
 <option value="1986" style="">
1986</option>
 <option value="1987" style="">

1987</option>
 <option value="1988" style="">
1988</option>
 <option value="1989" style="">

1989</option>
 <option value="1990" style="">
1990</option>
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1991</option>
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1992</option>
 <option value="1993" style="">

1993</option>
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1994</option>
 <option value="1995" style="">

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>
 <option value="2001" style="">

2001</option>
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2002</option>
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2003</option>
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2004</option>
 <option value="2005" style="">

2005</option>
 <option value="2006" style="">
2006</option>
 <option value="2007" style="">

2007</option>
 <option value="2008" style="">
2008</option>
 <option value="2009" style="">

2009</option>
 <option value="2010" style="">
2010</option>
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2011</option>
 <option value="2012" style="">
2012</option>
 <option value="2013" style="">

2013</option>
 <option value="2014" style="">
2014</option>
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2015</option>
 <option value="2016" style="">
2016</option>
 <option value="2017" style="">

2017</option>
 <option value="2018" style="">
2018</option>
 <option value="2019" selected="" style="">

2019</option>
 <option value="2020" style="">
2020</option>
 <option value="2021" style="">

2021</option>
 <option value="2022" style="">
2022</option>
 <option value="2023" style="">

2023</option>
 <option value="2024" style="">
2024</option>
 <option value="2025" style="">

2025</option>
 <option value="2026" style="">
2026</option>
 <option value="2027" style="">

2027</option>
 <option value="2028" style="">
2028</option>
 <option value="2029" style="">

2029</option>
 <option value="2030" style="">
2030</option>
 <option value="2031" style="">

2031</option>
 <option value="2032" style="">
2032</option>
 <option value="2033" style="">

2033</option>
 <option value="2034" style="">
2034</option>
 <option value="2035" style="">

2035</option>
 <option value="2036" style="">
2036</option>
 <option value="2037" style="">

2037</option>
 <option value="2038" style="">
2038</option>
 <option value="2039" style="">

2039</option>
 <option value="2040" style="">
2040</option>
 <option value="2041" style="">

2041</option>
 <option value="2042" style="">
2042</option>
 <option value="2043" style="">

2043</option>
 <option value="2044" style="">
2044</option>
 <option value="2045" style="">

2045</option>
 <option value="2046" style="">
2046</option>
 <option value="2047" style="">

2047</option>
 <option value="2048" style="">
2048</option>
 <option value="2049" style="">

2049</option>
 <option value="2050" style="">
2050</option>
 <option value="2051" style="">

2051</option>
 <option value="2052" style="">
2052</option>
 <option value="2053" style="">

2053</option>
 <option value="2054" style="">
2054</option>
 <option value="2055" style="">

2055</option>
 <option value="2056" style="">
2056</option>
 <option value="2057" style="">

2057</option>
 <option value="2058" style="">
2058</option>
 <option value="2059" style="">

2059</option>
 <option value="2060" style="">
2060</option>
 <option value="2061" style="">

2061</option>
 <option value="2062" style="">
2062</option>
 <option value="2063" style="">

2063</option>
 <option value="2064" style="">
2064</option>
 <option value="2065" style="">

2065</option>
 <option value="2066" style="">
2066</option>
 <option value="2067" style="">

2067</option>
 <option value="2068" style="">
2068</option>
 <option value="2069" style="">

2069</option>
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Tratamiento Realizado (si corresponde) </div>

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Derivación a otro Prestador Domiciliario </div>

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Sólo llene esta sección si es médico y solicita la visita de otro prestador del equipo</div>

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<ul class="ss-choices" role="group" aria-label="Derivación a otro Prestador Domiciliario Sólo llene esta sección si es médico y solicita la visita de otro prestador del equipo " style="list-style:none;padding:0;margin:.5em 0 0;">

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<input type="checkbox" name="entry.503039759" disabled="" checked="" value="ENFERMERA" id="group_503039759_1" role="checkbox" class="ss-q-checkbox" style="">
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ENFERMERA</span>
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<label>
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TENS</span>
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NUTRICIONISTA</span>
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<label>
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KINESIOLOGO</span>
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<label>
<span class="ss-choice-item-control goog-inline-block" style="position:relative;display:inline-block;">
<input type="checkbox" name="entry.503039759" disabled="" checked="" value="PSICOLOGO" id="group_503039759_5" role="checkbox" class="ss-q-checkbox" style="">
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PSICOLOGO</span>
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