<html>

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<body dir="auto">

<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>
 18 de junio de 2019, 7:24:45 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%;">

5176028-K</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%;">

Eliana Allendes </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="" selected="" 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="" 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%;">

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

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

1</option>
 <option value="2" disabled="" 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;">

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<label class="ss-scalenumber" for="group_1244707512_5" style="display:block;padding:0.5em 0 .5em;">
4</label>
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<label class="ss-scalenumber" for="group_1244707512_6" style="display:block;padding:0.5em 0 .5em;">
5</label>
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<label class="ss-scalenumber" for="group_1244707512_7" style="display:block;padding:0.5em 0 .5em;">
6</label>
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<label class="ss-scalenumber" for="group_1244707512_8" style="display:block;padding:0.5em 0 .5em;">
7</label>
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10</label>
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Escala Dolor EVA Mínimo </div>

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9</label>
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10</label>
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Paciente en buenas condiciones, asintomatica. Niega disnea. Deambula sin dificultad</div>

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Mucosas humedas, buena coloracion. Ruidos cardiacos ritmicos sin soplos. Pulmones claros ventilados, no agregados. Abdomen blando depresible,no dolor. EII se evidencia cicatriz con grapas cubierta con aposito limpio sin signos de infeccion, no secreción en
 región lateral externa de muslo derecho.</div>

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Cancer Bronquial</div>

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

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*</span>
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2 curaciones semanal Cuidados de la herida: no mojar Caminar Asistir a Urgencias en caso de dificultad respiratoria, fiebre</div>

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Medicamentos Indicados </div>

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Tratamiento Paliativo</div>

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

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Fecha aproximada del Próximo Control con usted </div>

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</div>

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<div class="ss-q-date" role="group" aria-label="Fecha aproximada del Próximo Control con usted  " 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;">

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<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" 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" selected="" 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>
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Mes</option>
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enero</option>
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febrero</option>
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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>
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<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>

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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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<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="ENFERMERA" id="group_503039759_1" role="checkbox" class="ss-q-checkbox" style="">
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ENFERMERA</span>
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<label>
<span class="ss-choice-item-control goog-inline-block" style="position:relative;display:inline-block;">
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TENS</span>
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<label>
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</span>

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NUTRICIONISTA</span>
 </label>
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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="KINESIOLOGO" id="group_503039759_4" role="checkbox" class="ss-q-checkbox" style="">
</span>

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KINESIOLOGO</span>
 </label>
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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="">
</span>

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

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