<div dir=3D"ltr">
<br>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class==3D"gmail_attr">
---------- Forwarded message ---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Formularios de Google</strong>
 <span dir=3D"auto">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: jue., 20 jun. 2019 a las 15:10<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:javieraleal.95@gmail.com">
javieraleal.95@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Formularios de Google" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por rellenar <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target=3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_-8412761632850563297ss-form-container">
<div class=3D"m_-8412761632850563297ss-form-heading">
<h1 class=3D"m_-8412761632850563297ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_-8412761632850563297ss-form-desc m_-8412761632850563297ss-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_-8412761632850563297ss-form">
<form method=3D"GET" id=3D"m_-8412761632850563297ss-form" target=3D"_blank">
<br>
<div class=3D"m_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-item-required m_-8412761632850563297ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8412761632850563297ss-q-item-label" for=3D"m_-8412761632850563297emailAddress">
<div class=3D"m_-8412761632850563297ss-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_-8412761632850563297emailAddress">
</label>
<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_-8412761632850563297ss-q-text m_-8412761632850563297ss-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:javieraleal.95@gmail.com" target=3D"_blank">
javieraleal.95@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8412761632850563297ss-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_-8412761632850563297ss-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_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8412761632850563297ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_-8412761632850563297ss-page-description m_-8412761632850563297ss-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_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-item-required m_-8412761632850563297ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8412761632850563297ss-q-item-label" for=3D"m_-8412761632850563297entry_579114469">
<div class=3D"m_-8412761632850563297ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_-8412761632850563297itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8412761632850563297ss-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%">
Javiera Leal </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-item-required m_-8412761632850563297ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8412761632850563297ss-q-item-label" for=3D"m_-8412761632850563297entry_1276273985">
<div class=3D"m_-8412761632850563297ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_-8412761632850563297itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-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_-8412761632850563297ss-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%">
18965132-5</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-item-required m_-8412761632850563297ss-select" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8412761632850563297ss-q-item-label" for=3D"m_-8412761632850563297entry_133691676">
<div class=3D"m_-8412761632850563297ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_-8412761632850563297itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-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_-8412761632850563297entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value=3D"NUTRICIONISTA" disabled selected>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8412761632850563297ss-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_-8412761632850563297ss-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_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8412761632850563297ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_-8412761632850563297ss-page-description m_-8412761632850563297ss-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_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8412761632850563297ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_-8412761632850563297ss-section-description m_-8412761632850563297ss-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_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-item-required m_-8412761632850563297ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8412761632850563297ss-q-item-label" for=3D"m_-8412761632850563297entry_823811303">
<div class=3D"m_-8412761632850563297ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_-8412761632850563297itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-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_-8412761632850563297ss-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%">
36025556-5</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-item-required m_-8412761632850563297ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8412761632850563297ss-q-item-label" for=3D"m_-8412761632850563297entry_1959365839">
<div class=3D"m_-8412761632850563297ss-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_-8412761632850563297itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8412761632850563297ss-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%">
Maria Romero</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-item-required m_-8412761632850563297ss-select" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8412761632850563297ss-q-item-label" for=3D"m_-8412761632850563297entry_545002227">
<div class=3D"m_-8412761632850563297ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_-8412761632850563297itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-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_-8412761632850563297entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled>
COLMENA</option>
 <option value=3D"CONSALUD" disabled selected>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled>
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled>
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-item-required m_-8412761632850563297ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8412761632850563297ss-q-item-label" for=3D"m_-8412761632850563297entry_1900161356">
<div class=3D"m_-8412761632850563297ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_-8412761632850563297itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8412761632850563297ss-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%">
Chiguayante</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-item-required m_-8412761632850563297ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8412761632850563297ss-q-item-label" for=3D"m_-8412761632850563297entry_1298871758">
<div class=3D"m_-8412761632850563297ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_-8412761632850563297itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8412761632850563297ss-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%">
Chiguayante</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8412761632850563297ss-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_-8412761632850563297ss-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_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8412761632850563297ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_-8412761632850563297ss-page-description m_-8412761632850563297ss-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_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-item-required m_-8412761632850563297ss-radio" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8412761632850563297ss-q-item-label" for=3D"m_-8412761632850563297entry_2073233714">
<div class=3D"m_-8412761632850563297ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_-8412761632850563297itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_-8412761632850563297ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-8412761632850563297ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-8412761632850563297ss-choice-item-control m_-8412761632850563297goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_-8412761632850563297group_1222378237_1" class=3D"m_-8412761632850563297ss-q-radio">
</span>
<span class=3D"m_-8412761632850563297ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_-8412761632850563297ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-8412761632850563297ss-choice-item-control m_-8412761632850563297goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_-8412761632850563297group_1222378237_2" class=3D"m_-8412761632850563297ss-q-radio">
</span>
<span class=3D"m_-8412761632850563297ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-item-required m_-8412761632850563297ss-date" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8412761632850563297ss-q-item-label" for=3D"m_-8412761632850563297entry_1705849412">
<div class=3D"m_-8412761632850563297ss-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_-8412761632850563297itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8412761632850563297ss-q-date">
<div class=3D"m_-8412761632850563297ss-datetime-box m_-8412761632850563297goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name=3D"entry.1705849412_day" disabled class=3D"m_-8412761632850563297ss-day-dropdown" id=3D"m_-8412761632850563297entry.1705849412_day">
<option value=3D"">
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>
 <option value=3D"5">
5</option>
 <option value=3D"6">
6</option>
 <option value=3D"7">
7</option>
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8</option>
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9</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value==3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20" selected>
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
</select>
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<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
 <option value=3D"2">
febrero</option>
 <option value=3D"3">
marzo</option>
 <option value=3D"4">
abril</option>
 <option value=3D"5">
mayo</option>
 <option value=3D"6" selected>
junio</option>
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julio</option>
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agosto</option>
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septiembre</option>
 <option value=3D"10">
octubre</option>
 <option value=3D"11">
noviembre</option>
 <option value=3D"12">
diciembre</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_-8412761632850563297entry.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>
 <option value=3D"1902">
1902</option>
 <option value=3D"1903">
1903</option>
 <option value=3D"1904">
1904</option>
 <option value=3D"1905">
1905</option>
 <option value=3D"1906">
1906</option>
 <option value=3D"1907">
1907</option>
 <option value=3D"1908">
1908</option>
 <option value=3D"1909">
1909</option>
 <option value=3D"1910">
1910</option>
 <option value=3D"1911">
1911</option>
 <option value=3D"1912">
1912</option>
 <option value=3D"1913">
1913</option>
 <option value=3D"1914">
1914</option>
 <option value=3D"1915">
1915</option>
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1916</option>
 <option value=3D"1917">
1917</option>
 <option value=3D"1918">
1918</option>
 <option value=3D"1919">
1919</option>
 <option value=3D"1920">
1920</option>
 <option value=3D"1921">
1921</option>
 <option value=3D"1922">
1922</option>
 <option value=3D"1923">
1923</option>
 <option value==3D"1924">
1924</option>
 <option value=3D"1925">
1925</option>
 <option value==3D"1926">
1926</option>
 <option value=3D"1927">
1927</option>
 <option value==3D"1928">
1928</option>
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1929</option>
 <option value==3D"1930">
1930</option>
 <option value=3D"1931">
1931</option>
 <option value==3D"1932">
1932</option>
 <option value=3D"1933">
1933</option>
 <option value==3D"1934">
1934</option>
 <option value=3D"1935">
1935</option>
 <option value==3D"1936">
1936</option>
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1937</option>
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1938</option>
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1939</option>
 <option value==3D"1940">
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>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
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1948</option>
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1949</option>
 <option value==3D"1950">
1950</option>
 <option value=3D"1951">
1951</option>
 <option value==3D"1952">
1952</option>
 <option value=3D"1953">
1953</option>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
 <option value=3D"1959">
1959</option>
 <option value==3D"1960">
1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
1976</option>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
 <option value==3D"1980">
1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
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2009</option>
 <option value==3D"2010">
2010</option>
 <option value=3D"2011">
2011</option>
 <option value==3D"2012">
2012</option>
 <option value=3D"2013">
2013</option>
 <option value==3D"2014">
2014</option>
 <option value=3D"2015">
2015</option>
 <option value==3D"2016">
2016</option>
 <option value=3D"2017">
2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-item-required m_-8412761632850563297ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8412761632850563297ss-q-item-label" for=3D"m_-8412761632850563297entry_206244955">
<div class=3D"m_-8412761632850563297ss-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_-8412761632850563297itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8412761632850563297ss-q-time">
<div class=3D"m_-8412761632850563297ss-datetime-box m_-8412761632850563297goog-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_-8412761632850563297entry.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>
 <option value=3D"05">
05</option>
 <option value=3D"06">
06</option>
 <option value=3D"07">
07</option>
 <option value=3D"08">
08</option>
 <option value=3D"09">
09</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13" selected>
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value==3D"22">
22</option>
 <option value=3D"23">
23</option>
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59</option>
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</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-item-required m_-8412761632850563297ss-select" style=3D"margin:12px 0">
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<div class=3D"m_-8412761632850563297ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_-8412761632850563297itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.1747608258" disabled id=3D"m_-8412761632850563297entry_1747608258">
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</option>
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0</option>
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1</option>
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2</option>
 <option value=3D"3" disabled>
3</option>
 <option value=3D"4" disabled>
4</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8412761632850563297ss-q-item-label" for=3D"m_-8412761632850563297entry_1716090865">
<div class=3D"m_-8412761632850563297ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-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_-8412761632850563297entry_1421689035">
<tbody>
<tr>
<td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1421689035_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1421689035_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
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<div class==3D"m_-8412761632850563297aria-todo">
</div>
</td>
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</div>
</td>
 <td class=3D"m_-8412761632850563297ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
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</div>
</td>
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<div class=3D"m_-8412761632850563297ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"2" id=3D"m_-8412761632850563297group_1421689035_3" class=3D"m_-8412761632850563297ss-q-radio">
</div>
</td>
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<div class=3D"m_-8412761632850563297ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3" id=3D"m_-8412761632850563297group_1421689035_4" class=3D"m_-8412761632850563297ss-q-radio">
</div>
</td>
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<div class=3D"m_-8412761632850563297ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_-8412761632850563297group_1421689035_5" class=3D"m_-8412761632850563297ss-q-radio">
</div>
</td>
 <td class=3D"m_-8412761632850563297ss-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_-8412761632850563297ss-scalerow-fieldcell">
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</div>
</td>
 <td class=3D"m_-8412761632850563297ss-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_-8412761632850563297ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_-8412761632850563297group_1421689035_7" class=3D"m_-8412761632850563297ss-q-radio">
</div>
</td>
 <td class=3D"m_-8412761632850563297ss-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_-8412761632850563297ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"7" id=3D"m_-8412761632850563297group_1421689035_8" class=3D"m_-8412761632850563297ss-q-radio">
</div>
</td>
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<div class=3D"m_-8412761632850563297ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_-8412761632850563297group_1421689035_9" class=3D"m_-8412761632850563297ss-q-radio">
</div>
</td>
 <td class=3D"m_-8412761632850563297ss-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_-8412761632850563297ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_-8412761632850563297group_1421689035_10" class=3D"m_-8412761632850563297ss-q-radio">
</div>
</td>
 <td class=3D"m_-8412761632850563297ss-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_-8412761632850563297ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"10" id=3D"m_-8412761632850563297group_1421689035_11" class=3D"m_-8412761632850563297ss-q-radio">
</div>
</td>
<td class=3D"m_-8412761632850563297ss-scalerow m_-8412761632850563297ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8412761632850563297ss-q-item-label" for=3D"m_-8412761632850563297entry_2064050596">
<div class=3D"m_-8412761632850563297ss-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_-8412761632850563297ss-q-help m_-8412761632850563297ss-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_-8412761632850563297entry_1244707512">
<tbody>
<tr>
<td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1244707512_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1244707512_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-8412761632850563297ss-scalerow m_-8412761632850563297ss-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_-8412761632850563297aria-todo">
</div>
</td>
<td class=3D"m_-8412761632850563297ss-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_-8412761632850563297ss-scalerow-fieldcell">
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<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
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<div class=3D"m_-8412761632850563297ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=ADnimo</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
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0</label>
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1</label>
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2</label>
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<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_853118630_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
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4</label>
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<label class=3D"m_-8412761632850563297ss-scalenumber" for==3D"m_-8412761632850563297group_853118630_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_853118630_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
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<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_853118630_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
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<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_853118630_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
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<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_853118630_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
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<label class=3D"m_-8412761632850563297ss-scalenumber" for=3D"m_-8412761632850563297group_853118630_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
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<td class=3D"m_-8412761632850563297ss-scalenumbers" style=3D"text-align:center">
</td>
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<div class==3D"m_-8412761632850563297aria-todo">
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</div>
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</div>
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</div>
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</div>
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</div>
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<div class=3D"m_-8412761632850563297ss-scalerow-fieldcell">
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</div>
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</div>
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<div class=3D"m_-8412761632850563297ss-scalerow-fieldcell">
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</div>
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</td>
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</div>
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<br>
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<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-item-required m_-8412761632850563297ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8412761632850563297ss-q-item-label" for=3D"m_-8412761632850563297entry_2140974612">
<div class=3D"m_-8412761632850563297ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Anamnesis/Evoluci=C3=B3n<label for=3D"m_-8412761632850563297itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8412761632850563297ss-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%">
Se realiza visita en homecare a se=C3=B1ora maria romero, quien se encuentra terminando su almuerzo, el cual consumi=C3=B3 en su totalidad (Ensalada, plato de fondo y postre), acompa=C3==B1ada, de muy buen animo, refiere hace dos d=C3=ADas haber tenido gases, los cuales actualmente desaparecieron, no ha tenido otras molestias, ni dolores, dice estar bien de apetito, consumiendo toda su comida (se ve registros de control de ingesta), solo que por =C2=A8gusto anoche no ceno, (hab=C3==ADa sopa crema de lentejas), pero lo reemplaza por un l=C3=A1cteo y compota de fruta.Pr=C3=B3xima semana se realiza evaluaci=C3=B3n antropom=C3=A9trica completa mensual.Peso:52kg (se mantiene)IMC: 23,1kg/m2Peso ideal: 56kg</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-item-required m_-8412761632850563297ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8412761632850563297ss-q-item-label" for=3D"m_-8412761632850563297entry_824006088">
<div class=3D"m_-8412761632850563297ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen F=C3=ADsico<label for=3D"m_-8412761632850563297itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8412761632850563297ss-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%">
Paciente en buen estado general, de muy buen =C3=A1nimoescleras rosadas, piel suave (un poco fr=C3=ADa), hidratadaAbdomen el dia de hoy sin molestiasPA: 117/76 FC 73Diuresis y deposiciones (+)EEII leve</div>
</div>
</div>
</div>
<br>
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<div dir=3D"auto" class=3D"m_-8412761632850563297ss-item m_-8412761632850563297ss-item-required m_-8412761632850563297ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8412761632850563297ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
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Diagn=C3=B3stico<label for=3D"m_-8412761632850563297itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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Paciente adulta mayor con estado nutricional normal (limite inferior), con composici=C3=B3n corporal grasa disminuida y muscular normal. Presenta suficiencia alimentaria.</div>
</div>
</div>
</div>
<br>
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<div class=3D"m_-8412761632850563297ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_-8412761632850563297itemView.getDomIdToLabel()">
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<span class=3D"m_-8412761632850563297ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
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</div>
</label>
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Requerimiento :=201960kcal/ d=C3=ADa, 56g/d=C3=ADa prote=C3=ADnas, CHO 294g/d=C3=ADa, Lipidos 63g/d=C3=ADaPrescripci=C3=B3n diet=C3=A9tica: R=C3=A9gimen blando hipercal=C3=B3rico, hipos=C3=B3dico, con restricci=C3=B3n de l=C3=ADquidos, horarios fraccionados.L=C3=ADquidos: 1000cc/d=C3=ADa*Se mantienen indicaciones de semana pasada.</div>
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Medicamentos Indicados</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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<div class=3D"m_-8412761632850563297ss-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)	Buprenorfina 35ug, =C2=BD parche cada 3 d=C3=ADas (ir rotando zona de aplicaci=C3=B3n)2)	Metamizol 300mg/12hrs vo=203)	Tramadol 10 gotas vo SOS=204)	Bisoprolol 5 mg/d=C3=ADa vo (dosis modificada por m=C3=A9dico de atenci==C3=B3n de urgencias el 15/05/19)5)	Olmesart=C3=A1n 20mg/d=C3=ADa vo (dosis modificada por cardi=C3=B3logo tratante)6)	Levotiroxina 25ug/d=C3=ADa vo (al menos media hr antes del desayuno)=207)	Escitalopran 10mg/d=C3=ADa vo=208)	Zolpidem 10mg/noche vo=209)	Furosemida 40mg am, 20 mg pm  vo (dosis modificada por cardi=C3=B3logo tratante)10)	Vitamina C, 1 comp efervescente al d=C3=ADa vo=2011)	Centrum silver 1 comp/d=C3=ADa vo=2012)	Lactulosa jarabe, 10-30cc/6-8hrs, lo necesario para 2-3 deposiciones semiformadas al d=C3=ADa13) Metoclopramida 10mg vo con el desayuno y almuerzo14) Quetiapina 25mg, 1,5 comp/noche (indicaci=C3=B3n de psiquiatra particular)</div>
</div>
</div>
</div>
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Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
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</div>
</label>
<div class=3D"m_-8412761632850563297ss-q-date">
<div class=3D"m_-8412761632850563297ss-datetime-box m_-8412761632850563297goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
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<option value=3D"">
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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<option value=3D"">
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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octubre</option>
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diciembre</option>
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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>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
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>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
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2037</option>
 <option value==3D"2038">
2038</option>
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2039</option>
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2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
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2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
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2050</option>
 <option value=3D"2051">
2051</option>
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2052</option>
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2053</option>
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2054</option>
 <option value=3D"2055">
2055</option>
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2056</option>
 <option value=3D"2057">
2057</option>
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2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8412761632850563297ss-form-question m_-8412761632850563297errorbox-good">
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Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8412761632850563297ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
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Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_-8412761632850563297ss-q-help m_-8412761632850563297ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
</label>
<ul class=3D"m_-8412761632850563297ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-8412761632850563297ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-8412761632850563297ss-choice-item-control m_-8412761632850563297goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"ENFERMERA" id=3D"m_-8412761632850563297group_503039759_1" class=3D"m_-8412761632850563297ss-q-checkbox">
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ENFERMERA</span>
</label>
</li>
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