<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: s=C3=A1b., 13 de jul. de 2019 a la(s) 12:15<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:luzmarialaraparejas@gmail.com">
luzmarialaraparejas@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 llenar <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">
Estas son tus respuestas:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_-8984263553552790462ss-form-container">
<div class=3D"m_-8984263553552790462ss-form-heading">
<h1 class=3D"m_-8984263553552790462ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_-8984263553552790462ss-form-desc m_-8984263553552790462ss-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_-8984263553552790462ss-form">
<form method=3D"GET" id=3D"m_-8984263553552790462ss-form" target=3D"_blank">
<br>
<div class=3D"m_-8984263553552790462ss-form-question m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-item-required m_-8984263553552790462ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8984263553552790462ss-q-item-label" for=3D"m_-8984263553552790462emailAddress">
<div class=3D"m_-8984263553552790462ss-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_-8984263553552790462emailAddress">
</label>
<span class=3D"m_-8984263553552790462ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_-8984263553552790462ss-q-text m_-8984263553552790462ss-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:luzmarialaraparejas@gmail.com" target=3D"_blank">
luzmarialaraparejas@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8984263553552790462ss-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_-8984263553552790462ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8984263553552790462ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_-8984263553552790462ss-page-description m_-8984263553552790462ss-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_-8984263553552790462ss-form-question m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-item-required m_-8984263553552790462ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8984263553552790462ss-q-item-label" for=3D"m_-8984263553552790462entry_579114469">
<div class=3D"m_-8984263553552790462ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_-8984263553552790462itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8984263553552790462ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8984263553552790462ss-q-help m_-8984263553552790462ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8984263553552790462ss-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%">
LUZ LARA</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8984263553552790462ss-form-question m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-item-required m_-8984263553552790462ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8984263553552790462ss-q-item-label" for=3D"m_-8984263553552790462entry_1276273985">
<div class=3D"m_-8984263553552790462ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_-8984263553552790462itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8984263553552790462ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8984263553552790462ss-q-help m_-8984263553552790462ss-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_-8984263553552790462ss-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%">
17759125-4</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8984263553552790462ss-form-question m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-item-required m_-8984263553552790462ss-select" style=3D"margin:12px 0">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8984263553552790462ss-q-item-label" for=3D"m_-8984263553552790462entry_133691676">
<div class=3D"m_-8984263553552790462ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_-8984263553552790462itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8984263553552790462ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8984263553552790462ss-q-help m_-8984263553552790462ss-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_-8984263553552790462entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled selected>
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>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8984263553552790462ss-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_-8984263553552790462ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8984263553552790462ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_-8984263553552790462ss-page-description m_-8984263553552790462ss-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_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8984263553552790462ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_-8984263553552790462ss-section-description m_-8984263553552790462ss-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_-8984263553552790462ss-form-question m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-item-required m_-8984263553552790462ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8984263553552790462ss-q-item-label" for=3D"m_-8984263553552790462entry_823811303">
<div class=3D"m_-8984263553552790462ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_-8984263553552790462itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8984263553552790462ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8984263553552790462ss-q-help m_-8984263553552790462ss-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_-8984263553552790462ss-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%">
23372096-8</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8984263553552790462ss-form-question m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-item-required m_-8984263553552790462ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8984263553552790462ss-q-item-label" for=3D"m_-8984263553552790462entry_1959365839">
<div class=3D"m_-8984263553552790462ss-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_-8984263553552790462itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8984263553552790462ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8984263553552790462ss-q-help m_-8984263553552790462ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8984263553552790462ss-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%">
FRANCISCO SOARES</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8984263553552790462ss-form-question m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-item-required m_-8984263553552790462ss-select" style=3D"margin:12px 0">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8984263553552790462ss-q-item-label" for=3D"m_-8984263553552790462entry_545002227">
<div class=3D"m_-8984263553552790462ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_-8984263553552790462itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8984263553552790462ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8984263553552790462ss-q-help m_-8984263553552790462ss-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_-8984263553552790462entry_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>
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 selected>
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_-8984263553552790462ss-form-question m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-item-required m_-8984263553552790462ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8984263553552790462ss-q-item-label" for=3D"m_-8984263553552790462entry_1900161356">
<div class=3D"m_-8984263553552790462ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_-8984263553552790462itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8984263553552790462ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8984263553552790462ss-q-help m_-8984263553552790462ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8984263553552790462ss-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%">
HUALPEN</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8984263553552790462ss-form-question m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-item-required m_-8984263553552790462ss-text" style=3D"margin:12px 0">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8984263553552790462ss-q-item-label" for=3D"m_-8984263553552790462entry_1298871758">
<div class=3D"m_-8984263553552790462ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_-8984263553552790462itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8984263553552790462ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8984263553552790462ss-q-help m_-8984263553552790462ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8984263553552790462ss-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%">
CONCEPCION</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8984263553552790462ss-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_-8984263553552790462ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-8984263553552790462ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_-8984263553552790462ss-page-description m_-8984263553552790462ss-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_-8984263553552790462ss-form-question m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-item-required m_-8984263553552790462ss-radio" style=3D"margin:12px 0">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8984263553552790462ss-q-item-label" for=3D"m_-8984263553552790462entry_2073233714">
<div class=3D"m_-8984263553552790462ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_-8984263553552790462itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8984263553552790462ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8984263553552790462ss-q-help m_-8984263553552790462ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_-8984263553552790462ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-8984263553552790462ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-8984263553552790462ss-choice-item-control m_-8984263553552790462goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_-8984263553552790462group_1222378237_1" class=3D"m_-8984263553552790462ss-q-radio">
</span>
<span class=3D"m_-8984263553552790462ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_-8984263553552790462ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-8984263553552790462ss-choice-item-control m_-8984263553552790462goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_-8984263553552790462group_1222378237_2" class=3D"m_-8984263553552790462ss-q-radio">
</span>
<span class=3D"m_-8984263553552790462ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8984263553552790462ss-form-question m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-item-required m_-8984263553552790462ss-date" style=3D"margin:12px 0">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8984263553552790462ss-q-item-label" for=3D"m_-8984263553552790462entry_1705849412">
<div class=3D"m_-8984263553552790462ss-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_-8984263553552790462itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8984263553552790462ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8984263553552790462ss-q-help m_-8984263553552790462ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8984263553552790462ss-q-date">
<div class=3D"m_-8984263553552790462ss-datetime-box m_-8984263553552790462goog-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_month" disabled class=3D"m_-8984263553552790462ss-month-dropdown" id=3D"m_-8984263553552790462entry.1705849412_month">
<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">
junio</option>
 <option value==3D"7" selected>
julio</option>
 <option value=3D"8">
agosto</option>
 <option value=3D"9">
septiembre</option>
 <option value=3D"10">
octubre</option>
 <option value=3D"11">
noviembre</option>
 <option value=3D"12">
diciembre</option>
</select>
   <select name=3D"entry.1705849412_day" disabled class=3D"m_-8984263553552790462ss-day-dropdown" id=3D"m_-8984263553552790462entry.1705849412_day">
<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
 <option value=3D"2">
2</option>
 <option value=3D"3">
3</option>
 <option value=3D"4">
4</option>
 <option value=3D"5">
5</option>
 <option value=3D"6">
6</option>
 <option value=3D"7">
7</option>
 <option value=3D"8">
8</option>
 <option value=3D"9">
9</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12" selected>
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">
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>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_-8984263553552790462entry.1705849412_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
 <option value=3D"1898">
1898</option>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
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>
 <option value=3D"1916">
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>
 <option value=3D"1929">
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>
 <option value=3D"1937">
1937</option>
 <option value==3D"1938">
1938</option>
 <option value=3D"1939">
1939</option>
 <option value==3D"1940">
1940</option>
 <option value=3D"1941">
1941</option>
 <option value==3D"1942">
1942</option>
 <option value=3D"1943">
1943</option>
 <option value==3D"1944">
1944</option>
 <option value=3D"1945">
1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
1948</option>
 <option value=3D"1949">
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>
 <option value=3D"2009">
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_-8984263553552790462ss-form-question m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-item-required m_-8984263553552790462ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8984263553552790462ss-q-item-label" for=3D"m_-8984263553552790462entry_206244955">
<div class=3D"m_-8984263553552790462ss-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_-8984263553552790462itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8984263553552790462ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8984263553552790462ss-q-help m_-8984263553552790462ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-8984263553552790462ss-q-time">
<div class=3D"m_-8984263553552790462ss-datetime-box m_-8984263553552790462goog-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_-8984263553552790462entry.206244955_hour">
<option value=3D"">
h</option>
<option value=3D"00">
00</option>
 <option value=3D"01">
01</option>
 <option value=3D"02">
02</option>
 <option value=3D"03">
03</option>
 <option value=3D"04">
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" selected>
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">
20</option>
 <option value=3D"21">
21</option>
 <option value==3D"22">
22</option>
 <option value=3D"23">
23</option>
</select>
.<select name=3D"entry.206244955_minute" disabled id=3D"m_-8984263553552790462entry.206244955_minute">
<option value=3D"">
min</option>
<option value=3D"00" selected>
00</option>
 <option value=3D"01">
01</option>
 <option value=3D"02">
02</option>
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03</option>
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04</option>
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05</option>
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06</option>
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07</option>
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08</option>
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09</option>
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10</option>
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11</option>
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12</option>
 <option value=3D"13">
13</option>
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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>
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22</option>
 <option value=3D"23">
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>
 <option value=3D"28">
28</option>
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29</option>
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30</option>
 <option value=3D"31">
31</option>
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32</option>
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33</option>
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34</option>
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35</option>
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36</option>
 <option value=3D"37">
37</option>
 <option value=3D"38">
38</option>
 <option value=3D"39">
39</option>
 <option value=3D"40">
40</option>
 <option value=3D"41">
41</option>
 <option value=3D"42">
42</option>
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43</option>
 <option value=3D"44">
44</option>
 <option value=3D"45">
45</option>
 <option value=3D"46">
46</option>
 <option value=3D"47">
47</option>
 <option value=3D"48">
48</option>
 <option value=3D"49">
49</option>
 <option value=3D"50">
50</option>
 <option value=3D"51">
51</option>
 <option value=3D"52">
52</option>
 <option value=3D"53">
53</option>
 <option value=3D"54">
54</option>
 <option value=3D"55">
55</option>
 <option value=3D"56">
56</option>
 <option value=3D"57">
57</option>
 <option value=3D"58">
58</option>
 <option value=3D"59">
59</option>
</select>
<div class=3D"m_-8984263553552790462ss-datetime-box-spacer m_-8984263553552790462goog-inline-block" style=3D"height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-8984263553552790462ss-form-question m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-item-required m_-8984263553552790462ss-select" style=3D"margin:12px 0">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8984263553552790462ss-q-item-label" for=3D"m_-8984263553552790462entry_1747608258">
<div class=3D"m_-8984263553552790462ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_-8984263553552790462itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-8984263553552790462ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-8984263553552790462ss-q-help m_-8984263553552790462ss-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_-8984263553552790462entry_1747608258">
<option value=3D"">
</option>
<option value=3D"0" disabled>
0</option>
 <option value=3D"1" disabled>
1</option>
 <option value=3D"2" disabled selected>
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_-8984263553552790462ss-form-question m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8984263553552790462ss-q-item-label" for=3D"m_-8984263553552790462entry_1716090865">
<div class=3D"m_-8984263553552790462ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_-8984263553552790462ss-q-help m_-8984263553552790462ss-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_-8984263553552790462entry_1421689035">
<tbody>
<tr>
<td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1421689035_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1421689035_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-8984263553552790462ss-scalerow m_-8984263553552790462ss-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_-8984263553552790462aria-todo">
</div>
</td>
<td class=3D"m_-8984263553552790462ss-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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<input type=3D"radio" name=3D"entry.1421689035" disabled checked value=3D"0" id==3D"m_-8984263553552790462group_1421689035_1" class=3D"m_-8984263553552790462ss-q-radio">
</div>
</td>
 <td class=3D"m_-8984263553552790462ss-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_-8984263553552790462ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"1" id=3D"m_-8984263553552790462group_1421689035_2" class=3D"m_-8984263553552790462ss-q-radio">
</div>
</td>
 <td class=3D"m_-8984263553552790462ss-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_-8984263553552790462ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"2" id=3D"m_-8984263553552790462group_1421689035_3" class=3D"m_-8984263553552790462ss-q-radio">
</div>
</td>
 <td class=3D"m_-8984263553552790462ss-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_-8984263553552790462ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3" id=3D"m_-8984263553552790462group_1421689035_4" class=3D"m_-8984263553552790462ss-q-radio">
</div>
</td>
 <td class=3D"m_-8984263553552790462ss-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_-8984263553552790462ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_-8984263553552790462group_1421689035_5" class=3D"m_-8984263553552790462ss-q-radio">
</div>
</td>
 <td class=3D"m_-8984263553552790462ss-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_-8984263553552790462ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_-8984263553552790462group_1421689035_6" class=3D"m_-8984263553552790462ss-q-radio">
</div>
</td>
 <td class=3D"m_-8984263553552790462ss-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_-8984263553552790462ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_-8984263553552790462group_1421689035_7" class=3D"m_-8984263553552790462ss-q-radio">
</div>
</td>
 <td class=3D"m_-8984263553552790462ss-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_-8984263553552790462ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"7" id=3D"m_-8984263553552790462group_1421689035_8" class=3D"m_-8984263553552790462ss-q-radio">
</div>
</td>
 <td class=3D"m_-8984263553552790462ss-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_-8984263553552790462ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_-8984263553552790462group_1421689035_9" class=3D"m_-8984263553552790462ss-q-radio">
</div>
</td>
 <td class=3D"m_-8984263553552790462ss-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_-8984263553552790462ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_-8984263553552790462group_1421689035_10" class=3D"m_-8984263553552790462ss-q-radio">
</div>
</td>
 <td class=3D"m_-8984263553552790462ss-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_-8984263553552790462ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"10" id=3D"m_-8984263553552790462group_1421689035_11" class=3D"m_-8984263553552790462ss-q-radio">
</div>
</td>
<td class=3D"m_-8984263553552790462ss-scalerow m_-8984263553552790462ss-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_-8984263553552790462ss-form-question m_-8984263553552790462errorbox-good">
<div dir=3D"auto" class=3D"m_-8984263553552790462ss-item m_-8984263553552790462ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-8984263553552790462ss-q-item-label" for=3D"m_-8984263553552790462entry_2064050596">
<div class=3D"m_-8984263553552790462ss-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_-8984263553552790462ss-q-help m_-8984263553552790462ss-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_-8984263553552790462entry_1244707512">
<tbody>
<tr>
<td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1244707512_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1244707512_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-8984263553552790462ss-scalenumber" for=3D"m_-8984263553552790462group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-8984263553552790462ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-8984263553552790462ss-scalerow m_-8984263553552790462ss-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_-8984263553552790462aria-todo">
</div>
</td>
<td class=3D"m_-8984263553552790462ss-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_-8984263553552790462ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled checked value=3D"0" id==3D"m_-8984263553552790462group_1244707512_1" class=3D"m_-8984263553552790462ss-q-radio">
</div>
</td>
 <td class=3D"m_-8984263553552790462ss-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_-8984263553552790462ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"1" id=3D"m_-8984263553552790462group_1244707512_2" class=3D"m_-8984263553552790462ss-q-radio">
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Escala Dolor EVA M=C3=ADnimo</div>
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0</label>
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2</label>
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3</label>
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5</label>
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6</label>
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7</label>
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8</label>
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9</label>
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10</label>
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Anamnesis/Evoluci=C3=B3n<label for=3D"m_-8984263553552790462itemView.getDomIdToLabel()">
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*</span>
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</div>
</label>
<div class=3D"m_-8984263553552790462ss-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 regulares condiciones generales, durante el fin de semana present=C3=B3 n=C3=A1useas, por lo que fue llevado a urgencias, donde se manejo con ondansetron, adem=C3=A1s se realizan examenes generales, resultando hemograma normal, solo destaca leve alteraciones electroliticas. =20Con respecto a sus controles con oncologo, fue visto por m=C3=A9dico tratante durante la semana, quien descart=C3=B3 nueva quimioterapia, a=C3=BAn en veremos el uso de radioterapia, con fines paliativos. Por su parte, su pareja se ha contactado con Centro Aleman en Santiago, como tratamiento complementario a su c=C3=A1ncer (paliativo), posiblemente, seg=C3=BAn presupuesto, pueda iniciar terapia la pr=C3=B3xima semana; cuentan con aprobaci=C3=B3n de onc=C3=B3logo.Actualmente en condiciones regulares, pero en comparaci=C3=B3n a semana anterior se manifiesta mejor=C3=ADa, est=C3=A1 tranquilo, m=C3=A1s reactivo, a veces pronuncia palabras inintelegibles, pero queda duda si es por su afasia o por barrera idiom=C3=A1tica (portugu=C3=A9s es su lengua natal). Deambula con base de sustentaci=C3=B3n aumentada, y sin dolor aparente. Luego de visita con oncologo, reinicia tratamiento con dexametasona, presentado buena tolerancia oral, hidrataci=C3=B3n adecuada. Deposiciones y diuresis de frecuencia diaria y caracter=C3=ADsticas normales.Cabe decir, que al hablar con la pareja del paciente, se vislumbra falta de conciencia, respecto al pronostico real de don Francisco. durante la visita tambien se encuentra la suegra del paciente, quien estuvo con oncologo, le pregunto las expectivas reales del caso, siendo poco alentadoras.</div>
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Examen F=C3=ADsico<label for=3D"m_-8984263553552790462itemView.getDomIdToLabel()">
</label>
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*</span>
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</div>
</label>
<div class=3D"m_-8984263553552790462ss-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%">
Signos vitalesPA: 130/70; FC: 98 lpm ; SatO2  97%; T=C2=BA: 36=C2=BAC=20Tranquilo, cooperador, lenguaje escaso y poco comprensible=20Cabeza y cuello: Normocr=C3=A1neo, mucosas hidratadas, conjuntivas  rosadas, escleras anict=C3=A9ricas y pupilas reactivas. No palpo adenopat=C3=ADas. Yugulares sin ingurgitaci=C3=B3n.Card=C3=ADaco: Ritmo regular en dos tiempos, no ausculto soplos.Pulmonar: Murmullo pulmonar presente hasta las bases, sin ruidos agregados.Abdomen: Blando, depresible y aparentemente indoloro. Ruidos hidroa=C3=A9reos positivos. No palpo masas ni visceromegalias. Sin signos de irritaci=C3==B3n peritoneal.Extremidades Inferiores: Presentes y m=C3=B3viles. Sin edema y sin signos de TVP.</div>
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Diagn=C3=B3stico<label for=3D"m_-8984263553552790462itemView.getDomIdToLabel()">
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*</span>
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Glioblastoma multiforme grado IV</div>
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Plan de Tratamiento e Indicaciones<label for=3D"m_-8984263553552790462itemView.getDomIdToLabel()">
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1) Oncol=C3=B3gico: Paciente con diagn=C3=B3stico de mal pron=C3=B3stico, ha sido manejado con cirug=C3=ADa, radioterapia y quimioterapia, siendo esta =C3=BAltima la m=C3=A1s reciente, y evaluada con RM  de cerebro, que seg=C3=BAn lo relatado por cuidadora, no se obtuvieron los resultados esperados. A la espera de resolucion de comite oncologico, por radioterapia paliativa, se dascarta nueva quimioterapia.=202) Analgesia: Actualmente sin episodios de dolor, se deja indicaci=C3=B3n de analgesia SOS. Observar evoluci=C3=B3n del dolor. Consultar en urgencia ante presencia de signos de alarma.3) Neurol=C3=B3gico: Mantener terapia anticonvulsivante, seg=C3=BAn indicaci=C3=B3n del especialista.4) Indicaciones generales: Alimentaci=C3=B3n e hidrataci=C3=B3n a tolerancia. Prevenci=C3=B3n de infecciones. Evitar exceso de estimulaci=C3=B3n sensorial (luces, sonidos, etc). Mantener controles semanales con medicia, enfermer=C3=ADa, kinesiolog=C3=ADa y psicolog=C3=ADa</div>
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Medicamentos Indicados</div>
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1) Keppra 500 mg cada 12 horas v=C3==ADa oral2) Dexametasona 4 mg cada 8 horas, v=C3=ADa oral3) Paracetamol 500 mg 1 a 2 comprimidos v=C3=ADa oral SOS4) Ondansetron 8mg 1 comprimido vo sos </div>
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Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
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<div class=3D"m_-8984263553552790462ss-datetime-box m_-8984263553552790462goog-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"">
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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noviembre</option>
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diciembre</option>
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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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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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1932</option>
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1933</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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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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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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1974</option>
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1975</option>
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1979</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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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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2005</option>
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2006</option>
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2007</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>
</div>
</div>
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 <div class=3D"m_-8984263553552790462ss-form-question m_-8984263553552790462errorbox-good">
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Tratamiento Realizado (si corresponde)</div>
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</div>
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Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_-8984263553552790462ss-q-help m_-8984263553552790462ss-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_-8984263553552790462ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-8984263553552790462ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
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<input type=3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"ENFERMERA" id=3D"m_-8984263553552790462group_503039759_1" class=3D"m_-8984263553552790462ss-q-checkbox">
</span>
<span class=3D"m_-8984263553552790462ss-choice-label">
ENFERMERA</span>
</label>
</li>
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<label>
<span class=3D"m_-8984263553552790462ss-choice-item-control m_-8984263553552790462goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_-8984263553552790462group_503039759_2" class=3D"m_-8984263553552790462ss-q-checkbox">
</span>
<span class=3D"m_-8984263553552790462ss-choice-label">
TENS</span>
</label>
</li>
 <li class=3D"m_-8984263553552790462ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
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<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id==3D"m_-8984263553552790462group_503039759_3" class=3D"m_-8984263553552790462ss-q-checkbox">
</span>
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NUTRICIONISTA</span>
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<input type=3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"PSICOLOGO" id=3D"m_-8984263553552790462group_503039759_5" class=3D"m_-8984263553552790462ss-q-checkbox">
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<div class=3D"m_-8984263553552790462ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
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<img class=3D"m_-8984263553552790462ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
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