<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: lun., 8 jul. 2019 23:58<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_2004086743407707165ss-form-container">
<div class=3D"m_2004086743407707165ss-form-heading">
<h1 class=3D"m_2004086743407707165ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_2004086743407707165ss-form-desc m_2004086743407707165ss-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_2004086743407707165ss-form">
<form method=3D"GET" id=3D"m_2004086743407707165ss-form" target=3D"_blank">
<br>
<div class=3D"m_2004086743407707165ss-form-question m_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-item-required m_2004086743407707165ss-text" style=3D"margin:12px 0">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2004086743407707165ss-q-item-label" for=3D"m_2004086743407707165emailAddress">
<div class=3D"m_2004086743407707165ss-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_2004086743407707165emailAddress">
</label>
<span class=3D"m_2004086743407707165ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_2004086743407707165ss-q-text m_2004086743407707165ss-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_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2004086743407707165ss-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_2004086743407707165ss-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_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2004086743407707165ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_2004086743407707165ss-page-description m_2004086743407707165ss-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_2004086743407707165ss-form-question m_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-item-required m_2004086743407707165ss-text" style=3D"margin:12px 0">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2004086743407707165ss-q-item-label" for=3D"m_2004086743407707165entry_579114469">
<div class=3D"m_2004086743407707165ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_2004086743407707165itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2004086743407707165ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2004086743407707165ss-q-help m_2004086743407707165ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2004086743407707165ss-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_2004086743407707165ss-form-question m_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-item-required m_2004086743407707165ss-text" style=3D"margin:12px 0">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2004086743407707165ss-q-item-label" for=3D"m_2004086743407707165entry_1276273985">
<div class=3D"m_2004086743407707165ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_2004086743407707165itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2004086743407707165ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2004086743407707165ss-q-help m_2004086743407707165ss-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_2004086743407707165ss-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_2004086743407707165ss-form-question m_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-item-required m_2004086743407707165ss-select" style=3D"margin:12px 0">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2004086743407707165ss-q-item-label" for=3D"m_2004086743407707165entry_133691676">
<div class=3D"m_2004086743407707165ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_2004086743407707165itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2004086743407707165ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2004086743407707165ss-q-help m_2004086743407707165ss-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_2004086743407707165entry_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_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2004086743407707165ss-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_2004086743407707165ss-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_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2004086743407707165ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_2004086743407707165ss-page-description m_2004086743407707165ss-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_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2004086743407707165ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_2004086743407707165ss-section-description m_2004086743407707165ss-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_2004086743407707165ss-form-question m_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-item-required m_2004086743407707165ss-text" style=3D"margin:12px 0">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2004086743407707165ss-q-item-label" for=3D"m_2004086743407707165entry_823811303">
<div class=3D"m_2004086743407707165ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_2004086743407707165itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2004086743407707165ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2004086743407707165ss-q-help m_2004086743407707165ss-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_2004086743407707165ss-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%">
7558632-9</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2004086743407707165ss-form-question m_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-item-required m_2004086743407707165ss-text" style=3D"margin:12px 0">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2004086743407707165ss-q-item-label" for=3D"m_2004086743407707165entry_1959365839">
<div class=3D"m_2004086743407707165ss-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_2004086743407707165itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2004086743407707165ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2004086743407707165ss-q-help m_2004086743407707165ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2004086743407707165ss-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%">
Isabel General</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_2004086743407707165ss-form-question m_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-item-required m_2004086743407707165ss-select" style=3D"margin:12px 0">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2004086743407707165ss-q-item-label" for=3D"m_2004086743407707165entry_545002227">
<div class=3D"m_2004086743407707165ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_2004086743407707165itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2004086743407707165ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2004086743407707165ss-q-help m_2004086743407707165ss-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_2004086743407707165entry_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_2004086743407707165ss-form-question m_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-item-required m_2004086743407707165ss-text" style=3D"margin:12px 0">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2004086743407707165ss-q-item-label" for=3D"m_2004086743407707165entry_1900161356">
<div class=3D"m_2004086743407707165ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_2004086743407707165itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2004086743407707165ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2004086743407707165ss-q-help m_2004086743407707165ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2004086743407707165ss-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_2004086743407707165ss-form-question m_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-item-required m_2004086743407707165ss-text" style=3D"margin:12px 0">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2004086743407707165ss-q-item-label" for=3D"m_2004086743407707165entry_1298871758">
<div class=3D"m_2004086743407707165ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_2004086743407707165itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2004086743407707165ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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<div class=3D"m_2004086743407707165ss-q-help m_2004086743407707165ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2004086743407707165ss-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_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2004086743407707165ss-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_2004086743407707165ss-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_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_2004086743407707165ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_2004086743407707165ss-page-description m_2004086743407707165ss-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_2004086743407707165ss-form-question m_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-item-required m_2004086743407707165ss-radio" style=3D"margin:12px 0">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2004086743407707165ss-q-item-label" for=3D"m_2004086743407707165entry_2073233714">
<div class=3D"m_2004086743407707165ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_2004086743407707165itemView.getDomIdToLabel()">
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<span class=3D"m_2004086743407707165ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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<div class=3D"m_2004086743407707165ss-q-help m_2004086743407707165ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
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<label>
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Domicilio</span>
</label>
</li>
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<label>
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<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_2004086743407707165group_1222378237_2" class=3D"m_2004086743407707165ss-q-radio">
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<span class=3D"m_2004086743407707165ss-choice-label">
Ambulatorio</span>
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</ul>
</div>
</div>
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<br>
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<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-item-required m_2004086743407707165ss-date" style=3D"margin:12px 0">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2004086743407707165ss-q-item-label" for=3D"m_2004086743407707165entry_1705849412">
<div class=3D"m_2004086743407707165ss-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_2004086743407707165itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2004086743407707165ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_2004086743407707165ss-q-help m_2004086743407707165ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2004086743407707165ss-q-date">
<div class=3D"m_2004086743407707165ss-datetime-box m_2004086743407707165goog-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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10</option>
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11</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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19</option>
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20</option>
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21</option>
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22</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>
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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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junio</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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1903</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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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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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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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
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2019</option>
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2020</option>
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2021</option>
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2022</option>
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2023</option>
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2024</option>
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2025</option>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
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2032</option>
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2033</option>
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2034</option>
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2035</option>
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2036</option>
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2037</option>
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2038</option>
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2039</option>
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2040</option>
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2041</option>
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2042</option>
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2043</option>
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2044</option>
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2045</option>
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2046</option>
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2047</option>
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2048</option>
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2049</option>
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2050</option>
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2051</option>
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2052</option>
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2053</option>
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2054</option>
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2055</option>
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2056</option>
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2057</option>
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2058</option>
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2059</option>
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2060</option>
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2061</option>
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2062</option>
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2063</option>
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2064</option>
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2065</option>
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2066</option>
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2067</option>
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2068</option>
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2069</option>
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</div>
</div>
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<div class=3D"m_2004086743407707165ss-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_2004086743407707165ss-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_2004086743407707165itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2004086743407707165ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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<div class=3D"m_2004086743407707165ss-q-help m_2004086743407707165ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_2004086743407707165ss-q-time">
<div class=3D"m_2004086743407707165ss-datetime-box m_2004086743407707165goog-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">
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h</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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10</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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22</option>
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23</option>
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03</option>
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04</option>
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06</option>
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07</option>
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09</option>
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10</option>
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11</option>
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13</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>
 <option value=3D"32">
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>
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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>
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44</option>
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45</option>
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46</option>
 <option value=3D"47">
47</option>
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48</option>
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49</option>
 <option value=3D"50">
50</option>
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51</option>
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52</option>
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53</option>
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54</option>
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55</option>
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56</option>
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57</option>
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58</option>
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59</option>
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</div>
</div>
</div>
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<div class=3D"m_2004086743407707165ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_2004086743407707165itemView.getDomIdToLabel()">
</label>
<span class=3D"m_2004086743407707165ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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<select name=3D"entry.1747608258" disabled id=3D"m_2004086743407707165entry_1747608258">
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</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>
</select>
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</div>
</div>
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 <div class=3D"m_2004086743407707165ss-form-question m_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_2004086743407707165ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_2004086743407707165ss-q-item-label" for=3D"m_2004086743407707165entry_1716090865">
<div class=3D"m_2004086743407707165ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_2004086743407707165ss-q-help m_2004086743407707165ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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</td>
<td class=3D"m_2004086743407707165ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_2004086743407707165ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
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2</label>
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<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
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<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
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<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
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<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
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<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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10</label>
</td>
<td class=3D"m_2004086743407707165ss-scalenumbers" style=3D"text-align:center">
</td>
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</div>
</td>
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</div>
<br>
 <div class=3D"m_2004086743407707165ss-form-question m_2004086743407707165errorbox-good">
<div dir=3D"auto" class=3D"m_2004086743407707165ss-item m_2004086743407707165ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_2004086743407707165ss-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_2004086743407707165ss-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_2004086743407707165ss-q-help m_2004086743407707165ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
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</td>
<td class=3D"m_2004086743407707165ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_2004086743407707165ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
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<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
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<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_2004086743407707165ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_2004086743407707165ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_2004086743407707165ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_2004086743407707165ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_2004086743407707165ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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<label class=3D"m_2004086743407707165ss-scalenumber" for=3D"m_2004086743407707165group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_2004086743407707165ss-scalenumbers" style=3D"text-align:center">
</td>
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<tr>
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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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3</label>
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5</label>
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6</label>
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8</label>
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9</label>
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10</label>
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Paciente con diagnostico de Ca Colon, vive sola en su casa, actualmente es cuidada por su hija Carolina, quien refiere que deambula al interior de la casa, con leve dificultad. Paciente al momento de la visita se encuentra en su cama en posicion supino, orientada en tiempo y espacio.=20Paciente con antecedentes de DM 2  y epilepsia ingreso el 19 de junio a la clinica Lircay por cuadro de rectorragia de 6 meses de evolucion  asociado a pujo. Se realiza TAC- TAP: multiples lesiones pulmonares y hepaticas asociado a lesion rectal T4B a utero.=20Ademas se realiza Colonoscopia  la cual indica neoplasia de recto medio/inferior, biopsiada.Paciente refiere:=20- Tabaco: (-)- Oh: (-)- Alergica: (-)-Apetito: Bueno- Nauseas: (+)-Vomitos: (+) Hematemesis- Diuresis: (+) en ba=C3=B1o- Deposiciones: (+)- Sue=C3=B1o: duerme poco por las noches-Sangrado en deposiciones: (+)- Picazon: (-)- Tos: (+) con flemas blancasCuidador nos muestra examenes realizados:- Calcio: 9.3-Creatinina: 0.8-Hematocrito: 27.6- Glicemia:121Cuidador refiere que este viernes debe viajar a Santiago con oncologo de Oncovida.</div>
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Al control de signos  vitales:P/A: 144/84FC: 76T: 36.4Sat: 99Piel: palida, deshidratadaCabeza: normocraneo, cabello cano, bien implantado.Torax: simetricoAbdomen: blando, depresibleExtremidades superiores: movilesExtremidades inferiores: moviles, edema (-)</div>
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Diagn=C3=B3stico<label for=3D"m_2004086743407707165itemView.getDomIdToLabel()">
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Ca Colon</div>
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Plan de Tratamiento e Indicaciones<label for=3D"m_2004086743407707165itemView.getDomIdToLabel()">
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1.- Control en una semana2.- Educacion farmacologica3.- Educacion cambios de posicion en cama4.- Educacion prevencion upp</div>
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Medicamentos Indicados</div>
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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>
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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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noviembre</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>
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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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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>
 <option value==3D"1994">
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>
 <option value==3D"2004">
2004</option>
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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>
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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>
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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>
 <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>
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2038</option>
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2044</option>
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2045</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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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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2068</option>
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2069</option>
</select>
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