<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: mi=C3=A9., 17 jul. 2019 a las 14:12<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:elizabethcorreadiaz@gmail.com">
elizabethcorreadiaz@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Formularios de Google" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por rellenar <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp==3Dmail_form_link" target=3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_6543364716917534405ss-form-container">
<div class=3D"m_6543364716917534405ss-form-heading">
<h1 class=3D"m_6543364716917534405ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_6543364716917534405ss-form-desc m_6543364716917534405ss-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_6543364716917534405ss-form">
<form method=3D"GET" id=3D"m_6543364716917534405ss-form" target=3D"_blank">
<br>
<div class=3D"m_6543364716917534405ss-form-question m_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-item-required m_6543364716917534405ss-text" style=3D"margin:12px 0">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6543364716917534405ss-q-item-label" for=3D"m_6543364716917534405emailAddress">
<div class=3D"m_6543364716917534405ss-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_6543364716917534405emailAddress">
</label>
<span class=3D"m_6543364716917534405ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_6543364716917534405ss-q-text m_6543364716917534405ss-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:elizabethcorreadiaz@gmail.com" target=3D"_blank">
elizabethcorreadiaz@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_6543364716917534405ss-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_6543364716917534405ss-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_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_6543364716917534405ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_6543364716917534405ss-page-description m_6543364716917534405ss-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_6543364716917534405ss-form-question m_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-item-required m_6543364716917534405ss-text" style=3D"margin:12px 0">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6543364716917534405ss-q-item-label" for=3D"m_6543364716917534405entry_579114469">
<div class=3D"m_6543364716917534405ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_6543364716917534405itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6543364716917534405ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6543364716917534405ss-q-help m_6543364716917534405ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6543364716917534405ss-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%">
ELIZABETH CORREA </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6543364716917534405ss-form-question m_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-item-required m_6543364716917534405ss-text" style=3D"margin:12px 0">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6543364716917534405ss-q-item-label" for=3D"m_6543364716917534405entry_1276273985">
<div class=3D"m_6543364716917534405ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_6543364716917534405itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6543364716917534405ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6543364716917534405ss-q-help m_6543364716917534405ss-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_6543364716917534405ss-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%">
16203285-2</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6543364716917534405ss-form-question m_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-item-required m_6543364716917534405ss-select" style=3D"margin:12px 0">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6543364716917534405ss-q-item-label" for=3D"m_6543364716917534405entry_133691676">
<div class=3D"m_6543364716917534405ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_6543364716917534405itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6543364716917534405ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6543364716917534405ss-q-help m_6543364716917534405ss-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_6543364716917534405entry_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_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_6543364716917534405ss-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_6543364716917534405ss-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_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_6543364716917534405ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_6543364716917534405ss-page-description m_6543364716917534405ss-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_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_6543364716917534405ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_6543364716917534405ss-section-description m_6543364716917534405ss-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_6543364716917534405ss-form-question m_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-item-required m_6543364716917534405ss-text" style=3D"margin:12px 0">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6543364716917534405ss-q-item-label" for=3D"m_6543364716917534405entry_823811303">
<div class=3D"m_6543364716917534405ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_6543364716917534405itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6543364716917534405ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6543364716917534405ss-q-help m_6543364716917534405ss-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_6543364716917534405ss-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%">
10553175-3</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6543364716917534405ss-form-question m_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-item-required m_6543364716917534405ss-text" style=3D"margin:12px 0">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6543364716917534405ss-q-item-label" for=3D"m_6543364716917534405entry_1959365839">
<div class=3D"m_6543364716917534405ss-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_6543364716917534405itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6543364716917534405ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6543364716917534405ss-q-help m_6543364716917534405ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6543364716917534405ss-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%">
HECTOR BARRERA</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6543364716917534405ss-form-question m_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-item-required m_6543364716917534405ss-select" style=3D"margin:12px 0">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6543364716917534405ss-q-item-label" for=3D"m_6543364716917534405entry_545002227">
<div class=3D"m_6543364716917534405ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_6543364716917534405itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6543364716917534405ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6543364716917534405ss-q-help m_6543364716917534405ss-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_6543364716917534405entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled selected>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled>
COLMENA</option>
 <option value=3D"CONSALUD" disabled>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled>
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled>
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_6543364716917534405ss-form-question m_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-item-required m_6543364716917534405ss-text" style=3D"margin:12px 0">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6543364716917534405ss-q-item-label" for=3D"m_6543364716917534405entry_1900161356">
<div class=3D"m_6543364716917534405ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_6543364716917534405itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6543364716917534405ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6543364716917534405ss-q-help m_6543364716917534405ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6543364716917534405ss-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%">
QUILPUE</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6543364716917534405ss-form-question m_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-item-required m_6543364716917534405ss-text" style=3D"margin:12px 0">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6543364716917534405ss-q-item-label" for=3D"m_6543364716917534405entry_1298871758">
<div class=3D"m_6543364716917534405ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_6543364716917534405itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6543364716917534405ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6543364716917534405ss-q-help m_6543364716917534405ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6543364716917534405ss-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%">
QUILPUE</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_6543364716917534405ss-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_6543364716917534405ss-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_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_6543364716917534405ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_6543364716917534405ss-page-description m_6543364716917534405ss-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_6543364716917534405ss-form-question m_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-item-required m_6543364716917534405ss-radio" style=3D"margin:12px 0">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6543364716917534405ss-q-item-label" for=3D"m_6543364716917534405entry_2073233714">
<div class=3D"m_6543364716917534405ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_6543364716917534405itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6543364716917534405ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6543364716917534405ss-q-help m_6543364716917534405ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_6543364716917534405ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_6543364716917534405ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_6543364716917534405ss-choice-item-control m_6543364716917534405goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_6543364716917534405group_1222378237_1" class=3D"m_6543364716917534405ss-q-radio">
</span>
<span class=3D"m_6543364716917534405ss-choice-label">
Domicilio</span>
</label>
</li>
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<label>
<span class=3D"m_6543364716917534405ss-choice-item-control m_6543364716917534405goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_6543364716917534405group_1222378237_2" class=3D"m_6543364716917534405ss-q-radio">
</span>
<span class=3D"m_6543364716917534405ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_6543364716917534405ss-form-question m_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-item-required m_6543364716917534405ss-date" style=3D"margin:12px 0">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6543364716917534405ss-q-item-label" for=3D"m_6543364716917534405entry_1705849412">
<div class=3D"m_6543364716917534405ss-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_6543364716917534405itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6543364716917534405ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6543364716917534405ss-q-help m_6543364716917534405ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6543364716917534405ss-q-date">
<div class=3D"m_6543364716917534405ss-datetime-box m_6543364716917534405goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
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D=C3=ADa</option>
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1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
</select>
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Mes</option>
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enero</option>
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febrero</option>
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marzo</option>
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abril</option>
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mayo</option>
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junio</option>
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julio</option>
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agosto</option>
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septiembre</option>
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octubre</option>
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noviembre</option>
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diciembre</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_6543364716917534405entry.1705849412_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
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2019</option>
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2020</option>
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2021</option>
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2022</option>
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2023</option>
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2024</option>
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2025</option>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
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2032</option>
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2033</option>
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2034</option>
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2035</option>
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2036</option>
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2037</option>
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2038</option>
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2039</option>
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2040</option>
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2041</option>
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2042</option>
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2043</option>
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2044</option>
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2045</option>
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2046</option>
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2047</option>
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2048</option>
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2049</option>
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2050</option>
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2051</option>
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2052</option>
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2053</option>
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2054</option>
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2055</option>
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2056</option>
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2057</option>
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2058</option>
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2059</option>
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2060</option>
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2061</option>
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2062</option>
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2063</option>
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2064</option>
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2065</option>
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2066</option>
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2067</option>
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2068</option>
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2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_6543364716917534405ss-form-question m_6543364716917534405errorbox-good">
<div dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-item-required m_6543364716917534405ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6543364716917534405ss-q-item-label" for=3D"m_6543364716917534405entry_206244955">
<div class=3D"m_6543364716917534405ss-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_6543364716917534405itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6543364716917534405ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_6543364716917534405ss-q-help m_6543364716917534405ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_6543364716917534405ss-q-time">
<div class=3D"m_6543364716917534405ss-datetime-box m_6543364716917534405goog-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_6543364716917534405entry.206244955_hour">
<option value=3D"">
h</option>
<option value=3D"00">
00</option>
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01</option>
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02</option>
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03</option>
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04</option>
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05</option>
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06</option>
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07</option>
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09</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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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
</select>
:<select name=3D"entry.206244955_minute" disabled id=3D"m_6543364716917534405entry.206244955_minute">
<option value=3D"">
min</option>
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00</option>
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01</option>
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02</option>
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03</option>
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04</option>
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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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14</option>
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17</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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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>
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39</option>
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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>
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47</option>
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48</option>
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49</option>
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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 class=3D"m_6543364716917534405ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_6543364716917534405itemView.getDomIdToLabel()">
</label>
<span class=3D"m_6543364716917534405ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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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 dir=3D"auto" class=3D"m_6543364716917534405ss-item m_6543364716917534405ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_6543364716917534405ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_6543364716917534405ss-q-item-label" for=3D"m_6543364716917534405entry_1716090865">
<div class=3D"m_6543364716917534405ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_6543364716917534405ss-q-help m_6543364716917534405ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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</td>
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<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
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<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_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_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
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<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
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<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
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<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
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<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
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9</label>
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10</label>
</td>
<td class=3D"m_6543364716917534405ss-scalenumbers" style=3D"text-align:center">
</td>
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<br>
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<div class=3D"m_6543364716917534405ss-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_6543364716917534405ss-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_6543364716917534405ss-q-help m_6543364716917534405ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
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<tr>
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</td>
<td class=3D"m_6543364716917534405ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_6543364716917534405ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
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<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
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<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_6543364716917534405ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_6543364716917534405ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_6543364716917534405ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
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<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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<label class=3D"m_6543364716917534405ss-scalenumber" for=3D"m_6543364716917534405group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_6543364716917534405ss-scalenumbers" style=3D"text-align:center">
</td>
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Escala Dolor EVA M=C3=ADnimo</div>
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0</label>
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3</label>
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4</label>
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5</label>
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6</label>
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7</label>
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8</label>
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9</label>
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10</label>
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Medicamentos Indicados</div>
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SALBUTAMOL 2 PUF C/ 6 HRS X 5 DIASAMBROXOL 10 ML C/ 8 HRS X 5 DIASPARACETAMOL SOS EN CASO DE FIEBREKINE RESPIRATORIA ADICIONAL </div>
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Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
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D=C3=ADa</option>
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22</option>
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1920</option>
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1968</option>
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1970</option>
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1971</option>
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1972</option>
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1982</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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1990</option>
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1991</option>
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1992</option>
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1993</option>
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2000</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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Tratamiento Realizado (si corresponde)</div>
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Derivaci=C3=B3n a otro Prestador Domiciliario</div>
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S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
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