<div dir=3D"auto">
</div>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class=3D"gmail_attr">
---------- Forwarded message ---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Formularios de Google</strong>
 <span dir=3D"auto">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: mar., 18 jun. 2019 22:23<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:eveortegaa@gmail.com">
eveortegaa@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Formularios de Google" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por rellenar <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target=3D"_blank" rel=3D"noreferrer">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_4171340102671340770ss-form-container">
<div class=3D"m_4171340102671340770ss-form-heading">
<h1 class=3D"m_4171340102671340770ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_4171340102671340770ss-form-desc m_4171340102671340770ss-no-ignore-whitespace" style=3D"font:inherit;width:99%;margin:0 0 1em;white-space:pre-wrap;word-wrap:break-word">
Este es el sistema de registro de atenciones domiciliarias de Oncovida.   Debe ser llenado por el prestador individual, y debe realizarse un registro por cada visita domiciliaria.   Si usted no es prestador de Oncovida por favor no llene este formulario.   A continuaci=C3=B3n indique su correo electr=C3=B3nico.</div>
</div>
<div class=3D"m_4171340102671340770ss-form">
<form method=3D"GET" id=3D"m_4171340102671340770ss-form" target=3D"_blank">
<br>
<div class=3D"m_4171340102671340770ss-form-question m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-item-required m_4171340102671340770ss-text" style=3D"margin:12px 0">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4171340102671340770ss-q-item-label" for=3D"m_4171340102671340770emailAddress">
<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Direcci=C3==B3n de correo electr=C3=B3nico<label for=3D"m_4171340102671340770emailAddress">
</label>
<span class=3D"m_4171340102671340770ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_4171340102671340770ss-q-text m_4171340102671340770ss-printable-text-line" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
<a href=3D"mailto:eveortegaa@gmail.com" target=3D"_blank" rel=3D"noreferrer">
eveortegaa@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_4171340102671340770ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_4171340102671340770ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_4171340102671340770ss-page-description m_4171340102671340770ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
Aqu=C3=AD debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770ss-form-question m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-item-required m_4171340102671340770ss-text" style=3D"margin:12px 0">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4171340102671340770ss-q-item-label" for=3D"m_4171340102671340770entry_579114469">
<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_4171340102671340770itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4171340102671340770ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4171340102671340770ss-q-help m_4171340102671340770ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_4171340102671340770ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Evelyn Ortega</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770ss-form-question m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-item-required m_4171340102671340770ss-text" style=3D"margin:12px 0">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4171340102671340770ss-q-item-label" for=3D"m_4171340102671340770entry_1276273985">
<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_4171340102671340770itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4171340102671340770ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4171340102671340770ss-q-help m_4171340102671340770ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_4171340102671340770ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
16273226-9</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770ss-form-question m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-item-required m_4171340102671340770ss-select" style=3D"margin:12px 0">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4171340102671340770ss-q-item-label" for=3D"m_4171340102671340770entry_133691676">
<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_4171340102671340770itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4171340102671340770ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4171340102671340770ss-q-help m_4171340102671340770ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
Si asisten m=C3=A1s de 1 prestador simult=C3=A1neamente, cada uno debe hacer un registro independiente</div>
</label>
<select name=3D"entry.133691676" disabled id=3D"m_4171340102671340770entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled selected>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_4171340102671340770ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_4171340102671340770ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_4171340102671340770ss-page-description m_4171340102671340770ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_4171340102671340770ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_4171340102671340770ss-section-description m_4171340102671340770ss-no-ignore-whitespace" style=3D"margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770ss-form-question m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-item-required m_4171340102671340770ss-text" style=3D"margin:12px 0">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4171340102671340770ss-q-item-label" for=3D"m_4171340102671340770entry_823811303">
<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_4171340102671340770itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4171340102671340770ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4171340102671340770ss-q-help m_4171340102671340770ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_4171340102671340770ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
6131208-0</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770ss-form-question m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-item-required m_4171340102671340770ss-text" style=3D"margin:12px 0">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4171340102671340770ss-q-item-label" for=3D"m_4171340102671340770entry_1959365839">
<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente<label for=3D"m_4171340102671340770itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4171340102671340770ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4171340102671340770ss-q-help m_4171340102671340770ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_4171340102671340770ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Luis Soto</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770ss-form-question m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-item-required m_4171340102671340770ss-select" style=3D"margin:12px 0">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4171340102671340770ss-q-item-label" for=3D"m_4171340102671340770entry_545002227">
<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_4171340102671340770itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4171340102671340770ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4171340102671340770ss-q-help m_4171340102671340770ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.545002227" disabled id=3D"m_4171340102671340770entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled selected>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled>
COLMENA</option>
 <option value=3D"CONSALUD" disabled>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled>
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled>
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770ss-form-question m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-item-required m_4171340102671340770ss-text" style=3D"margin:12px 0">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4171340102671340770ss-q-item-label" for=3D"m_4171340102671340770entry_1900161356">
<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_4171340102671340770itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4171340102671340770ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4171340102671340770ss-q-help m_4171340102671340770ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_4171340102671340770ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Talca</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770ss-form-question m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-item-required m_4171340102671340770ss-text" style=3D"margin:12px 0">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4171340102671340770ss-q-item-label" for=3D"m_4171340102671340770entry_1298871758">
<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_4171340102671340770itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4171340102671340770ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4171340102671340770ss-q-help m_4171340102671340770ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_4171340102671340770ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Talca</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_4171340102671340770ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_4171340102671340770ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_4171340102671340770ss-page-description m_4171340102671340770ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos de la atenci==C3=B3n domiciliaria</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770ss-form-question m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-item-required m_4171340102671340770ss-radio" style=3D"margin:12px 0">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4171340102671340770ss-q-item-label" for=3D"m_4171340102671340770entry_2073233714">
<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_4171340102671340770itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4171340102671340770ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4171340102671340770ss-q-help m_4171340102671340770ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_4171340102671340770ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_4171340102671340770ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_4171340102671340770ss-choice-item-control m_4171340102671340770goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_4171340102671340770group_1222378237_1" class=3D"m_4171340102671340770ss-q-radio">
</span>
<span class=3D"m_4171340102671340770ss-choice-label">
Domicilio</span>
</label>
</li>
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<label>
<span class=3D"m_4171340102671340770ss-choice-item-control m_4171340102671340770goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_4171340102671340770group_1222378237_2" class=3D"m_4171340102671340770ss-q-radio">
</span>
<span class=3D"m_4171340102671340770ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770ss-form-question m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-item-required m_4171340102671340770ss-date" style=3D"margin:12px 0">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4171340102671340770ss-q-item-label" for=3D"m_4171340102671340770entry_1705849412">
<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha de la Atenci=C3=B3n<label for=3D"m_4171340102671340770itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4171340102671340770ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4171340102671340770ss-q-help m_4171340102671340770ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_4171340102671340770ss-q-date">
<div class=3D"m_4171340102671340770ss-datetime-box m_4171340102671340770goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
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D=C3=ADa</option>
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1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
</select>
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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>
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octubre</option>
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noviembre</option>
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diciembre</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_4171340102671340770entry.1705849412_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
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2019</option>
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2020</option>
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2021</option>
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2022</option>
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2023</option>
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2024</option>
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2025</option>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
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2032</option>
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2033</option>
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2034</option>
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2035</option>
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2036</option>
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2037</option>
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2038</option>
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2039</option>
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2040</option>
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2041</option>
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2042</option>
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2043</option>
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2044</option>
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2045</option>
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2046</option>
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2047</option>
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2048</option>
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2049</option>
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2050</option>
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2051</option>
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2052</option>
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2053</option>
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2054</option>
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2055</option>
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2056</option>
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2057</option>
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2058</option>
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2059</option>
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2060</option>
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2061</option>
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2062</option>
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2063</option>
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2064</option>
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2065</option>
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2066</option>
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2067</option>
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2068</option>
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2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770ss-form-question m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-item-required m_4171340102671340770ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4171340102671340770ss-q-item-label" for=3D"m_4171340102671340770entry_206244955">
<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Hora de la Atenci=C3=B3n<label for=3D"m_4171340102671340770itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4171340102671340770ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_4171340102671340770ss-q-help m_4171340102671340770ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_4171340102671340770ss-q-time">
<div class=3D"m_4171340102671340770ss-datetime-box m_4171340102671340770goog-inline-block" dir=3D"ltr" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
<select name=3D"entry.206244955_hour" disabled id=3D"m_4171340102671340770entry.206244955_hour">
<option value=3D"">
h</option>
<option value=3D"00">
00</option>
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01</option>
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02</option>
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03</option>
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04</option>
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05</option>
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06</option>
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07</option>
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08</option>
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09</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
</select>
:<select name=3D"entry.206244955_minute" disabled id=3D"m_4171340102671340770entry.206244955_minute">
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min</option>
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00</option>
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01</option>
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02</option>
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03</option>
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04</option>
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05</option>
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06</option>
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07</option>
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08</option>
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09</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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17</option>
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18</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
 <option value=3D"29">
29</option>
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30</option>
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31</option>
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32</option>
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33</option>
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34</option>
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35</option>
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36</option>
 <option value=3D"37">
37</option>
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38</option>
 <option value=3D"39">
39</option>
 <option value=3D"40">
40</option>
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41</option>
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42</option>
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43</option>
 <option value=3D"44">
44</option>
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45</option>
 <option value=3D"46">
46</option>
 <option value=3D"47">
47</option>
 <option value=3D"48">
48</option>
 <option value=3D"49">
49</option>
 <option value=3D"50">
50</option>
 <option value=3D"51">
51</option>
 <option value=3D"52">
52</option>
 <option value=3D"53">
53</option>
 <option value=3D"54">
54</option>
 <option value=3D"55">
55</option>
 <option value=3D"56">
56</option>
 <option value=3D"57">
57</option>
 <option value=3D"58">
58</option>
 <option value=3D"59">
59</option>
</select>
<div class=3D"m_4171340102671340770ss-datetime-box-spacer m_4171340102671340770goog-inline-block" style=3D"height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
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<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-item-required m_4171340102671340770ss-select" style=3D"margin:12px 0">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4171340102671340770ss-q-item-label" for=3D"m_4171340102671340770entry_1747608258">
<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_4171340102671340770itemView.getDomIdToLabel()">
</label>
<span class=3D"m_4171340102671340770ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
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</div>
</label>
<select name=3D"entry.1747608258" disabled id=3D"m_4171340102671340770entry_1747608258">
<option value=3D"">
</option>
<option value=3D"0" disabled>
0</option>
 <option value=3D"1" disabled>
1</option>
 <option value=3D"2" disabled>
2</option>
 <option value=3D"3" disabled>
3</option>
 <option value=3D"4" disabled selected>
4</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770ss-form-question m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4171340102671340770ss-q-item-label" for=3D"m_4171340102671340770entry_1716090865">
<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_4171340102671340770ss-q-help m_4171340102671340770ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_4171340102671340770entry_1421689035">
<tr>
<td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
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<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1421689035_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
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<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_4171340102671340770ss-scalerow m_4171340102671340770ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_4171340102671340770aria-todo">
</div>
</td>
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</div>
</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled checked value==3D"1" id=3D"m_4171340102671340770group_1421689035_2" class=3D"m_4171340102671340770ss-q-radio">
</div>
</td>
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</div>
</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3" id=3D"m_4171340102671340770group_1421689035_4" class=3D"m_4171340102671340770ss-q-radio">
</div>
</td>
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<div class=3D"m_4171340102671340770ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_4171340102671340770group_1421689035_5" class=3D"m_4171340102671340770ss-q-radio">
</div>
</td>
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<div class=3D"m_4171340102671340770ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_4171340102671340770group_1421689035_6" class=3D"m_4171340102671340770ss-q-radio">
</div>
</td>
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<div class=3D"m_4171340102671340770ss-scalerow-fieldcell">
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</div>
</td>
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</div>
</td>
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</div>
</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_4171340102671340770group_1421689035_10" class=3D"m_4171340102671340770ss-q-radio">
</div>
</td>
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<div class==3D"m_4171340102671340770ss-scalerow-fieldcell">
<input type=3D"radio" name==3D"entry.1421689035" disabled value=3D"10" id=3D"m_4171340102671340770group_1421689035_11" class=3D"m_4171340102671340770ss-q-radio">
</div>
</td>
<td class=3D"m_4171340102671340770ss-scalerow m_4171340102671340770ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770ss-form-question m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_4171340102671340770ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_4171340102671340770ss-q-item-label" for=3D"m_4171340102671340770entry_2064050596">
<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=A1ximo</div>
<div class=3D"m_4171340102671340770ss-q-help m_4171340102671340770ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_4171340102671340770entry_1244707512">
<tr>
<td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_4171340102671340770ss-scalenumber" for=3D"m_4171340102671340770group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_4171340102671340770ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_4171340102671340770ss-scalerow m_4171340102671340770ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_4171340102671340770aria-todo">
</div>
</td>
<td class=3D"m_4171340102671340770ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_4171340102671340770ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"0" id=3D"m_4171340102671340770group_1244707512_1" class=3D"m_4171340102671340770ss-q-radio">
</div>
</td>
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<div class=3D"m_4171340102671340770ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"1" id=3D"m_4171340102671340770group_1244707512_2" class=3D"m_4171340102671340770ss-q-radio">
</div>
</td>
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<div class=3D"m_4171340102671340770ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled checked value=3D"2" id=3D"m_4171340102671340770group_1244707512_3" class=3D"m_4171340102671340770ss-q-radio">
</div>
</td>
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<div class=3D"m_4171340102671340770ss-scalerow-fieldcell">
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</div>
</td>
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<div class=3D"m_4171340102671340770ss-scalerow-fieldcell">
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Escala Dolor EVA M=C3=ADnimo</div>
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0</label>
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1</label>
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2</label>
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3</label>
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4</label>
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5</label>
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6</label>
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7</label>
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8</label>
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9</label>
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10</label>
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</td>
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Anamnesis/Evoluci=C3=B3n<label for=3D"m_4171340102671340770itemView.getDomIdToLabel()">
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Paciente en posicion semi fowler en su catre clinico, con colchon antiescara, desorientado, cuidador refiere que ha estado mucho mejor, con poco dolor, con buen animo, buen apetito, se desorienta por periodos cortos durante el dia, pero mas en la noche.Nauseas: (-)Vomitos: (-)Sue=C3=B1o: despierta en las noches para pedir aguaDiuresis: (+) en pa=C3=B1alDeposiciones: (+) en pa=C3=B1alO2:  (+) 2 a 3 litrosTos: (+)Flemas: (-)Cansancio/ debilidad: (+)Alucinaciones: (+)</div>
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<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen F=C3=ADsico<label for=3D"m_4171340102671340770itemView.getDomIdToLabel()">
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*</span>
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Al control de signos vitales:P/A: 135/67FC: 68T: 36.1Sat: 92 con uso de O2Glicemia antes del desayuno: 108 mg/dlGlicemia antes del almuerzo: 104 mg/dlPiel: indemneUPP: (-)Torax: tonelAbdomen: blando, depresible, indoloro, hernia paraumbilical derechaExt sup: movilesExt inferiores: moviles, edema (-), pulsos (+)Mucositis: (-)</div>
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Diagn=C3=B3stico<label for=3D"m_4171340102671340770itemView.getDomIdToLabel()">
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Ca de pulmon</div>
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Plan de Tratamiento e Indicaciones<label for=3D"m_4171340102671340770itemView.getDomIdToLabel()">
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1.- Control en 7 d=C3=ACas2.- Reforzamiento farmacologico3.- Reforzamiento en prevencion de UPP</div>
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Medicamentos Indicados</div>
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</div>
</label>
<div class=3D"m_4171340102671340770ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
1.- Insulina 16 u2.- Zeolita3.-Codeisol 5 gotas 3 veces al dia4.- Tramadol 15 gotas cada 6 horas5.- Transtec 1 parche cada 3 dias6.- Clopidrogel7.- Bisoprolol8.- Monopack 1/29.- Inhalador Berodual 2 puff cada 4 horas10.- Goteli11.- Dolginal cada  SOS12.- Domperidona 1 cada 8 horas13.- oxigeno 2 o 3 lts uso permanente por naricera14.- Ondasentron 4 mg uno al dia15.- Lactulosa 220cc cada 4 horas16.- Pregabalina17.- Ciruelax</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_4171340102671340770ss-form-question m_4171340102671340770errorbox-good">
<div dir=3D"auto" class=3D"m_4171340102671340770ss-item m_4171340102671340770ss-date" style=3D"margin:12px 0">
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<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_4171340102671340770ss-q-help m_4171340102671340770ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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<div class=3D"m_4171340102671340770ss-q-date">
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D=C3=ADa</option>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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Mes</option>
<option value=3D"1">
enero</option>
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febrero</option>
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marzo</option>
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abril</option>
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mayo</option>
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junio</option>
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julio</option>
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agosto</option>
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septiembre</option>
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diciembre</option>
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A=C3=B1o</option>
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1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
 <option value==3D"1964">
1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
 <option value==3D"1972">
1972</option>
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1973</option>
 <option value==3D"1974">
1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
 <option value=3D"1979">
1979</option>
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1980</option>
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1981</option>
 <option value==3D"1982">
1982</option>
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1983</option>
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1984</option>
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1985</option>
 <option value==3D"1986">
1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
 <option value==3D"2000">
2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
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2019</option>
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2020</option>
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2021</option>
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2022</option>
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2023</option>
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2024</option>
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2025</option>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
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2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
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2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
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2069</option>
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</div>
</div>
</div>
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<br>
 <div class=3D"m_4171340102671340770ss-form-question m_4171340102671340770errorbox-good">
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<div class=3D"m_4171340102671340770ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_4171340102671340770ss-q-help m_4171340102671340770ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_4171340102671340770ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
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Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_4171340102671340770ss-q-help m_4171340102671340770ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
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<ul class=3D"m_4171340102671340770ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
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<span class=3D"m_4171340102671340770ss-choice-label">
ENFERMERA</span>
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</li>
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<label>
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</span>
<span class=3D"m_4171340102671340770ss-choice-label">
TENS</span>
</label>
</li>
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<label>
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<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id==3D"m_4171340102671340770group_503039759_3" class=3D"m_4171340102671340770ss-q-checkbox">
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<span class=3D"m_4171340102671340770ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
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<label>
<span class=3D"m_4171340102671340770ss-choice-item-control m_4171340102671340770goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"KINESIOLOGO" id=3D"m_4171340102671340770group_503039759_4" class=3D"m_4171340102671340770ss-q-checkbox">
</span>
<span class=3D"m_4171340102671340770ss-choice-label">
KINESIOLOGO</span>
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<label>
<span class=3D"m_4171340102671340770ss-choice-item-control m_4171340102671340770goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"PSICOLOGO" id=3D"m_4171340102671340770group_503039759_5" class=3D"m_4171340102671340770ss-q-checkbox">
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<span class=3D"m_4171340102671340770ss-choice-label">
PSICOLOGO</span>
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