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EU Sandra Maulen Angel<div>
Coordinadora</div>
<div>
Telemed-Chile</div>
<=/div>
<div dir=3D"ltr">
<br>
Inicio del mensaje reenviado:<br>
<br>
</div>
<blockq=uote type=3D"cite">
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<b>
De:</b>
 "Dra. IVY ANDREA CONTRERAS VI=LLAMIZAR" &lt;<a href=3D"mailto:ivycom_villamizar@hotmail.com">
ivycom_villam=izar@hotmail.com</a>
&gt;<br>
<b>
Fecha:</b>
 1 de agosto de 2019, 20:25:58 CLT<=br>
<b>
Para:</b>
 "<a href=3D"mailto:coordinadora@telemed-chile.cl">
coordinado=ra@telemed-chile.cl</a>
" &lt;<a href=3D"mailto:coordinadora@telemed-chile.cl=">
coordinadora@telemed-chile.cl</a>
&gt;<br>
<b>
Asunto:</b>
 <b>
RV: Registro de= Atenci=C3=B3n Domiciliaria Oncovida</b>
<br>
<br>
</div>
</blockquote>
<blockquo=te type=3D"cite">
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<meta http-equiv=3D"Content-Type" content=3D"text/html; charset=3Diso-8859-1=">
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<div style=3D"font-family: Calibri, Helvetica, sans-serif; font-size: 12pt; c=olor: rgb(0, 0, 0);">
ESTIMADA SE LO ENIO</div>
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<hr tabindex=3D"-1" style=3D"display:inline-block; width:98%">
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<font face=3D"Calibri, sans-serif" col=or=3D"#000000" style=3D"font-size:11pt">
<b>
De:</b>
 Formularios de Google &lt=;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply=@google.com</a>
&gt;<br>
<b>
Enviado:</b>
 jueves, 1 de agosto de 2019 6:35 p. m.<br>
<b>
Para:</b>
 <a href=3D"mailto:ivycom_villamizar@hotmail.com">
ivycom_villami=zar@hotmail.com</a>
 &lt;<a href=3D"mailto:ivycom_villamizar@hotmail.com">
ivy=com_villamizar@hotmail.com</a>
&gt;<br>
<b>
Asunto:</b>
 Registro de Atenci=C3=B3n Domiciliaria Oncovida</font>
<div>
&nbsp;</div>
</div>
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<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%" role=3D="presentation" style=3D"background-color:rgb(38,4,154)">
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<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Formularios de Google" height=3D="26px" width=3D"143px" style=3D"display:inline-block; margin:0; vertical-ali=gn:middle" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_locku=p_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 soli=d #e0e0e0; margin:0 auto; max-width:624px; min-width:154px; padding:0 24px">
=<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%" r=ole=3D"presentation" style=3D"background-color:#fff">
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<tr height=3D"24px">
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<div style=3D"font-size:13px; line-height:18px; color:#424242; font-weight:7=00">
Gracias por llenar<a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKM=wg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link">
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"ss-form-container" style=3D"">
<div class=3D"ss-form-heading" style=3D"">
<h1 class=3D"ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de= Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"ss-form-desc ss-no-ignore-whitespace" style=3D"font:inherit; w=idth: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 c=ada visita domiciliaria. Si usted no es prestador de Oncovida por favor no l=lene este formulario. A continuaci=C3=B3n indique su correo electr=C3=B3nico.</div>
</div>
<div class=3D"ss-form" style=3D"">
<form action=3D"" method=3D"GET" id=3D"ss-form" style=3D"">
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"emailAddress" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Direcci=C3=B3n de correo electr=C3=B3nico <label for=3D"emailAddress" aria-l=abel=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"c=olor:#c43b1d">
*</span>
</div>
</label>
<div class=3D"ss-q-text ss-printable-text-line" dir=3D"auto" style=3D"backgr=ound-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white=-space:pre-wrap; color:#545454; width:70%">
<a href=3D"mailto:ivycom_villamizar@hotmail.com">
ivycom_villamizar@hotmail.c=om</a>
</div>
</div>
</div>
</div>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style=3D="margin:12px 0; max-width:100%">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-to=p:.83em; margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"ss-image" title=3D"" alt=3D"Im=agen sin t=C3=ADtulo" style=3D"width:78px; outline:none" src=3D"https://lh3.=googleusercontent.com/00-FWRRIiJNpjLIXj1QrTLVceHhiPxWpIN-K4cI0enEtAvmFFnvOHR=JTMz5Lq8yFpMHz7WvBnNdiNVchE6Snklpxxc7gIx3OoqTfn_sB2_iSp_6sx7Sr2pww-0pD">
</di=v>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-page-title" style=3D"padding:0.4em; background-color:#eee">
I=dentificaci=C3=B3n del Prestador</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" dir=3D"auto" styl=e=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"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_579114469" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Primer Nombre y Apellido Paterno <label for=3D"itemView.getDomIdToLabel()" a=ria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"c=olor:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee; max-wi=dth:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:=#545454; width:70%">
Ivy contreras</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1276273985" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
RUT <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligator=io)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"c=olor:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; margin:.1em 0 .25em 0; color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</d=iv>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee; max-wi=dth:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:=#545454; width:70%">
25923363-1</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-select" style=3D"marg=in:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_133691676" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Tipo <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligato=rio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"c=olor:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; 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=3D"" id=3D"entry_133691676=" aria-label=3D"Tipo Si asisten m=C3=A1s de 1 prestador simult=C3=A1neamente=, cada uno debe hacer un registro independiente " style=3D"">
<option value=3D="" style=3D"">
</option>
 <option value=3D"MEDICO" disabled=3D"" selected=3D"" style=3D"">
ME=DICO</option>
<option value=3D"ENFERMERA/O" disabled=3D"" style=3D"">
ENFERMERA/O</option>
 <=option value=3D"TENS" disabled=3D"" style=3D"">
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled=3D"" style=3D"">
KINES=IOLOGA/O</option>
<option value=3D"PSICOLOGO" disabled=3D"" style=3D"">
PSICOLOGO</option>
 <opt=ion value=3D"NUTRICIONISTA" disabled=3D"" style=3D"">
NUTRICIONISTA</option>
</select>
 </div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style=3D="margin:12px 0; max-width:100%">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-to=p:.83em; margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"ss-image" title=3D"" alt=3D"Im=agen sin t=C3=ADtulo" style=3D"width:78px; outline:none" src=3D"https://lh3.=googleusercontent.com/mRJInQVKRU12r9blREv2jmlzETLT9JfIHWC0FaeXYfPraPFE9ebBRX=8P_hmpfiBP6BNpOgjPBYU0zwBxYxgoLvjQ7EjfjoRTJ2_-8flTaiU_wC008XC8LpcEJ_Yp">
</di=v>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-page-title" style=3D"padding:0.4em; background-color:#eee">
I=dentificaci=C3=B3n del Paciente</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" dir=3D"auto" styl=e=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"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-section-header" style=3D"margin:12px 0=">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-section-title" style=3D"background-color:#eee; padding:0.4em=">
Datos Personales del Paciente</h2>
<div class=3D"ss-section-description ss-no-ignore-whitespace" style=3D"margi=n-top:0.5em; white-space:pre-wrap; word-wrap:break-word">
</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_823811303" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Ingrese el Rut del Paciente <label for=3D"itemView.getDomIdToLabel()" aria-l=abel=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"c=olor:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; margin:.1em 0 .25em 0; color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</d=iv>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee; max-wi=dth:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:=#545454; width:70%">
9103278-3</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1959365839" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente <label for=3D"itemV=iew.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"c=olor:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee; max-wi=dth:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:=#545454; width:70%">
Sergio carrizo</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-select" style=3D"marg=in:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_545002227" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Previsi=C3=B3n <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Camp=o obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"c=olor:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<select name=3D"entry.545002227" disabled=3D"" id=3D"entry_545002227=" aria-label=3D"Previsi=C3=B3n  " style=3D"">
<option value=3D"" style=3D"">
</option>
 <option value=3D"BANMEDICA" disabled=3D"" style=3D"">
BANMEDICA</op=tion>
 <option value=3D"CAPREDENA" disabled=3D"" style=3D"">
CAPREDENA</option>
 <option value=3D"COLMENA" disabled=3D"" style=3D"">
COLMEN=A</option>
 <option value=3D"CONSALUD" disabled=3D"" style=3D"">
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled=3D"" style=3D"">
CRU=Z BLANCA</option>
<option value=3D"DIPRECA" disabled=3D"" style=3D"">
DIPRECA</option>
 <option v=alue=3D"FONASA" disabled=3D"" style=3D"">
FONASA</option>
 <option value=3D"FUNDACION" disabled=3D"" style=3D"">
FUNDACI=ON</option>
<option value=3D"ISAPRES DEL COBRE" disabled=3D"" style=3D"">
ISAPRES DEL COB=RE</option>
<option value=3D"NUEVA MASVIDA" disabled=3D"" selected=3D"" style=3D"">
NUEVA= MASVIDA</option>
<option value=3D"VIDATRES" disabled=3D"" style=3D"">
VIDATRES</option>
 <optio=n value=3D"PARTICULAR" disabled=3D"" style=3D"">
PARTICULAR</option>
</select>
 </div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1900161356" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Ciudad <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obliga=torio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"c=olor:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee; max-wi=dth:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:=#545454; width:70%">
Tierra amarilla</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1298871758" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Comuna <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obliga=torio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"c=olor:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee; max-wi=dth:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:=#545454; width:70%">
Tierra amarilla</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style=3D="margin:12px 0; max-width:100%">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-to=p:.83em; margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"ss-image" title=3D"" alt=3D"Im=agen sin t=C3=ADtulo" style=3D"width:78px; outline:none" src=3D"https://lh6.=googleusercontent.com/URytM0QWRGW_JEL0xQxvOLvwPRJIHyqlnKOm6ky9DRBfzvYVPaAngX=V35GNHnaVG-dm9Orno4lr8sy8E-KB9tMrmIhFbVQiOPWy3vUclqRKAJ51dvLdhjBKgXdLO">
</di=v>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-page-title" style=3D"padding:0.4em; background-color:#eee">
R=egistro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" dir=3D"auto" styl=e=3D"white-space:pre-wrap; word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos de la atenci=C3=B3n domiciliari=a</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-radio" style=3D"margi=n:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_2073233714" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Tipo de Atenci=C3=B3n <label for=3D"itemView.getDomIdToLabel()" aria-label=3D="(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"c=olor:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<ul class=3D"ss-choices" role=3D"radiogroup" aria-label=3D"Tipo de Atenci=C3==B3n  " style=3D"list-style:none; padding:0; margin:.5em 0 0">
<li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-b=ottom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"dis=play:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled=3D="" checked=3D"" value=3D"Domicilio" id=3D"group_1222378237_1" role=3D"radio"= class=3D"ss-q-radio" aria-label=3D"Domicilio" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
Domicilio</span>
 </label>
</li>
<li= class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bott=om:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"dis=play:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled=3D="" value=3D"Ambulatorio" id=3D"group_1222378237_2" role=3D"radio" class=3D"s=s-q-radio" aria-label=3D"Ambulatorio" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
Ambulatorio</span>
 </label>
</li>
<=/ul>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-date" style=3D"margin=:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1705849412" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Fecha de la Atenci=C3=B3n <label for=3D"itemView.getDomIdToLabel()" aria-lab=el=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"c=olor:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-date" role=3D"group" aria-label=3D"Fecha de la Atenci=C3=B3=n  " style=3D"">
<div class=3D"ss-datetime-box goog-inline-block" role=3D"group" style=3D"bor=der:1px solid #dcdcdc; margin-right:2em; min-height:32px; padding-left:3px; v=ertical-align:middle; margin:4px 3px; display:inline-block">
<select name=3D"entry.1705849412_month" disabled=3D"" class=3D"ss-month-drop=down" id=3D"entry.1705849412_month" aria-label=3D"Mes" style=3D"">
<option va=lue=3D"" style=3D"">
Mes</option>
 <option value=3D"1" style=3D"">
enero</option>
 <option value=3D"=2" style=3D"">
febrero</option>
 <option value=3D"3" style=3D"">
marzo</option>
 <option value==3D"4" style=3D"">
abril</option>
 <option value=3D"5" style=3D"">
mayo</option>
 <option value=3D="6" style=3D"">
junio</option>
 <option value=3D"7" selected=3D"" style=3D"">
julio</option>
 <=option value=3D"8" style=3D"">
agosto</option>
 <option value=3D"9" style=3D"">
septiembre</option>
 <option v=alue=3D"10" style=3D"">
octubre</option>
 <option value=3D"11" style=3D"">
noviembre</option>
 <option v=alue=3D"12" style=3D"">
diciembre</option>
</select>
 <select name=3D"entry.1705849412_day" disabled=3D="" class=3D"ss-day-dropdown" id=3D"entry.1705849412_day" aria-label=3D"D=C3=AD=a del mes" style=3D"">
<option value=3D"" style=3D"">
D=C3=ADa</option>
 <option value=3D"1" style=3D"">
1</option>
 <option value=3D="2" style=3D"">
2</option>
<option value=3D"3" style=3D"">
3</option>
 <option value=3D"4" style=3D"">
4</=option>
 <option value=3D"5" style=3D"">
5</option>
 <option value=3D"6" style=3D"">
6</option>
 <option value=3D"7" sty=le=3D"">
7</option>
<option value=3D"8" style=3D"">
8</option>
 <option value=3D"9" style=3D"">
9</=option>
 <option value=3D"10" style=3D"">
10</option>
 <option value=3D"11" style=3D"">
11</option>
 <option value=3D"12"= style=3D"">
12</option>
 <option value=3D"13" style=3D"">
13</option>
 <option value=3D"14" s=tyle=3D"">
14</option>
<option value=3D"15" style=3D"">
15</option>
 <option value=3D"16" style=3D"">
=16</option>
 <option value=3D"17" style=3D"">
17</option>
 <option value=3D"18" style=3D"">
18</option>
 <option value=3D"19"= style=3D"">
19</option>
 <option value=3D"20" style=3D"">
20</option>
 <option value=3D"21" s=tyle=3D"">
21</option>
<option value=3D"22" style=3D"">
22</option>
 <option value=3D"23" style=3D"">
=23</option>
 <option value=3D"24" style=3D"">
24</option>
 <option value=3D"25" style=3D"">
25</option>
 <option value=3D"26"= selected=3D"" style=3D"">
26</option>
 <option value=3D"27" style=3D"">
27</option>
 <option value=3D"28"= style=3D"">
28</option>
 <option value=3D"29" style=3D"">
29</option>
 <option value=3D"30" s=tyle=3D"">
30</option>
<option value=3D"31" style=3D"">
31</option>
</select>
 <select name=3D"entry.1=705849412_year" disabled=3D"" id=3D"entry.1705849412_year" aria-label=3D"A=C3==B1o" style=3D"">
<option value=3D"" style=3D"">
A=C3=B1o</option>
 <option value=3D"1896" style=3D"">
1896</option>
 <option va=lue=3D"1897" style=3D"">
1897</option>
 <option value=3D"1898" style=3D"">
1898</option>
 <option value=3D="1899" style=3D"">
1899</option>
 <option value=3D"1900" style=3D"">
1900</option>
 <option value=3D="1901" style=3D"">
1901</option>
 <option value=3D"1902" style=3D"">
1902</option>
 <option value=3D="1903" style=3D"">
1903</option>
 <option value=3D"1904" style=3D"">
1904</option>
 <option value=3D="1905" style=3D"">
1905</option>
 <option value=3D"1906" style=3D"">
1906</option>
 <option value=3D="1907" style=3D"">
1907</option>
 <option value=3D"1908" style=3D"">
1908</option>
 <option value=3D="1909" style=3D"">
1909</option>
 <option value=3D"1910" style=3D"">
1910</option>
 <option value=3D="1911" style=3D"">
1911</option>
 <option value=3D"1912" style=3D"">
1912</option>
 <option value=3D="1913" style=3D"">
1913</option>
 <option value=3D"1914" style=3D"">
1914</option>
 <option value=3D="1915" style=3D"">
1915</option>
 <option value=3D"1916" style=3D"">
1916</option>
 <option value=3D="1917" style=3D"">
1917</option>
 <option value=3D"1918" style=3D"">
1918</option>
 <option value=3D="1919" style=3D"">
1919</option>
 <option value=3D"1920" style=3D"">
1920</option>
 <option value=3D="1921" style=3D"">
1921</option>
 <option value=3D"1922" style=3D"">
1922</option>
 <option value=3D="1923" style=3D"">
1923</option>
 <option value=3D"1924" style=3D"">
1924</option>
 <option value=3D="1925" style=3D"">
1925</option>
 <option value=3D"1926" style=3D"">
1926</option>
 <option value=3D="1927" style=3D"">
1927</option>
 <option value=3D"1928" style=3D"">
1928</option>
 <option value=3D="1929" style=3D"">
1929</option>
 <option value=3D"1930" style=3D"">
1930</option>
 <option value=3D="1931" style=3D"">
1931</option>
 <option value=3D"1932" style=3D"">
1932</option>
 <option value=3D="1933" style=3D"">
1933</option>
 <option value=3D"1934" style=3D"">
1934</option>
 <option value=3D="1935" style=3D"">
1935</option>
 <option value=3D"1936" style=3D"">
1936</option>
 <option value=3D="1937" style=3D"">
1937</option>
 <option value=3D"1938" style=3D"">
1938</option>
 <option value=3D="1939" style=3D"">
1939</option>
 <option value=3D"1940" style=3D"">
1940</option>
 <option value=3D="1941" style=3D"">
1941</option>
 <option value=3D"1942" style=3D"">
1942</option>
 <option value=3D="1943" style=3D"">
1943</option>
 <option value=3D"1944" style=3D"">
1944</option>
 <option value=3D="1945" style=3D"">
1945</option>
 <option value=3D"1946" style=3D"">
1946</option>
 <option value=3D="1947" style=3D"">
1947</option>
 <option value=3D"1948" style=3D"">
1948</option>
 <option value=3D="1949" style=3D"">
1949</option>
 <option value=3D"1950" style=3D"">
1950</option>
 <option value=3D="1951" style=3D"">
1951</option>
 <option value=3D"1952" style=3D"">
1952</option>
 <option value=3D="1953" style=3D"">
1953</option>
 <option value=3D"1954" style=3D"">
1954</option>
 <option value=3D="1955" style=3D"">
1955</option>
 <option value=3D"1956" style=3D"">
1956</option>
 <option value=3D="1957" style=3D"">
1957</option>
 <option value=3D"1958" style=3D"">
1958</option>
 <option value=3D="1959" style=3D"">
1959</option>
 <option value=3D"1960" style=3D"">
1960</option>
 <option value=3D="1961" style=3D"">
1961</option>
 <option value=3D"1962" style=3D"">
1962</option>
 <option value=3D="1963" style=3D"">
1963</option>
 <option value=3D"1964" style=3D"">
1964</option>
 <option value=3D="1965" style=3D"">
1965</option>
 <option value=3D"1966" style=3D"">
1966</option>
 <option value=3D="1967" style=3D"">
1967</option>
 <option value=3D"1968" style=3D"">
1968</option>
 <option value=3D="1969" style=3D"">
1969</option>
 <option value=3D"1970" style=3D"">
1970</option>
 <option value=3D="1971" style=3D"">
1971</option>
 <option value=3D"1972" style=3D"">
1972</option>
 <option value=3D="1973" style=3D"">
1973</option>
 <option value=3D"1974" style=3D"">
1974</option>
 <option value=3D="1975" style=3D"">
1975</option>
 <option value=3D"1976" style=3D"">
1976</option>
 <option value=3D="1977" style=3D"">
1977</option>
 <option value=3D"1978" style=3D"">
1978</option>
 <option value=3D="1979" style=3D"">
1979</option>
 <option value=3D"1980" style=3D"">
1980</option>
 <option value=3D="1981" style=3D"">
1981</option>
 <option value=3D"1982" style=3D"">
1982</option>
 <option value=3D="1983" style=3D"">
1983</option>
 <option value=3D"1984" style=3D"">
1984</option>
 <option value=3D="1985" style=3D"">
1985</option>
 <option value=3D"1986" style=3D"">
1986</option>
 <option value=3D="1987" style=3D"">
1987</option>
 <option value=3D"1988" style=3D"">
1988</option>
 <option value=3D="1989" style=3D"">
1989</option>
 <option value=3D"1990" style=3D"">
1990</option>
 <option value=3D="1991" style=3D"">
1991</option>
 <option value=3D"1992" style=3D"">
1992</option>
 <option value=3D="1993" style=3D"">
1993</option>
 <option value=3D"1994" style=3D"">
1994</option>
 <option value=3D="1995" style=3D"">
1995</option>
 <option value=3D"1996" style=3D"">
1996</option>
 <option value=3D="1997" style=3D"">
1997</option>
 <option value=3D"1998" style=3D"">
1998</option>
 <option value=3D="1999" style=3D"">
1999</option>
 <option value=3D"2000" style=3D"">
2000</option>
 <option value=3D="2001" style=3D"">
2001</option>
 <option value=3D"2002" style=3D"">
2002</option>
 <option value=3D="2003" style=3D"">
2003</option>
 <option value=3D"2004" style=3D"">
2004</option>
 <option value=3D="2005" style=3D"">
2005</option>
 <option value=3D"2006" style=3D"">
2006</option>
 <option value=3D="2007" style=3D"">
2007</option>
 <option value=3D"2008" style=3D"">
2008</option>
 <option value=3D="2009" style=3D"">
2009</option>
 <option value=3D"2010" style=3D"">
2010</option>
 <option value=3D="2011" style=3D"">
2011</option>
 <option value=3D"2012" style=3D"">
2012</option>
 <option value=3D="2013" style=3D"">
2013</option>
 <option value=3D"2014" style=3D"">
2014</option>
 <option value=3D="2015" style=3D"">
2015</option>
 <option value=3D"2016" style=3D"">
2016</option>
 <option value=3D="2017" style=3D"">
2017</option>
 <option value=3D"2018" style=3D"">
2018</option>
 <option value=3D="2019" selected=3D"" style=3D"">
2019</option>
 <option value=3D"2020" style=3D"">
2020</option>
 <option value=3D="2021" style=3D"">
2021</option>
 <option value=3D"2022" style=3D"">
2022</option>
 <option value=3D="2023" style=3D"">
2023</option>
 <option value=3D"2024" style=3D"">
2024</option>
 <option value=3D="2025" style=3D"">
2025</option>
 <option value=3D"2026" style=3D"">
2026</option>
 <option value=3D="2027" style=3D"">
2027</option>
 <option value=3D"2028" style=3D"">
2028</option>
 <option value=3D="2029" style=3D"">
2029</option>
 <option value=3D"2030" style=3D"">
2030</option>
 <option value=3D="2031" style=3D"">
2031</option>
 <option value=3D"2032" style=3D"">
2032</option>
 <option value=3D="2033" style=3D"">
2033</option>
 <option value=3D"2034" style=3D"">
2034</option>
 <option value=3D="2035" style=3D"">
2035</option>
 <option value=3D"2036" style=3D"">
2036</option>
 <option value=3D="2037" style=3D"">
2037</option>
 <option value=3D"2038" style=3D"">
2038</option>
 <option value=3D="2039" style=3D"">
2039</option>
 <option value=3D"2040" style=3D"">
2040</option>
 <option value=3D="2041" style=3D"">
2041</option>
 <option value=3D"2042" style=3D"">
2042</option>
 <option value=3D="2043" style=3D"">
2043</option>
 <option value=3D"2044" style=3D"">
2044</option>
 <option value=3D="2045" style=3D"">
2045</option>
 <option value=3D"2046" style=3D"">
2046</option>
 <option value=3D="2047" style=3D"">
2047</option>
 <option value=3D"2048" style=3D"">
2048</option>
 <option value=3D="2049" style=3D"">
2049</option>
 <option value=3D"2050" style=3D"">
2050</option>
 <option value=3D="2051" style=3D"">
2051</option>
 <option value=3D"2052" style=3D"">
2052</option>
 <option value=3D="2053" style=3D"">
2053</option>
 <option value=3D"2054" style=3D"">
2054</option>
 <option value=3D="2055" style=3D"">
2055</option>
 <option value=3D"2056" style=3D"">
2056</option>
 <option value=3D="2057" style=3D"">
2057</option>
 <option value=3D"2058" style=3D"">
2058</option>
 <option value=3D="2059" style=3D"">
2059</option>
 <option value=3D"2060" style=3D"">
2060</option>
 <option value=3D="2061" style=3D"">
2061</option>
 <option value=3D"2062" style=3D"">
2062</option>
 <option value=3D="2063" style=3D"">
2063</option>
 <option value=3D"2064" style=3D"">
2064</option>
 <option value=3D="2065" style=3D"">
2065</option>
 <option value=3D"2066" style=3D"">
2066</option>
 <option value=3D="2067" style=3D"">
2067</option>
 <option value=3D"2068" style=3D"">
2068</option>
 <option value=3D="2069" style=3D"">
2069</option>
</select>
 </div>
</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-time" style=3D"margin=:12px 0; font:inherit">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_206244955" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Hora de la Atenci=C3=B3n <label for=3D"itemView.getDomIdToLabel()" aria-labe=l=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"c=olor:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-time" style=3D"">
<div class=3D"ss-datetime-box goog-inline-block" dir=3D"ltr" style=3D"border=:1px solid #dcdcdc; margin-right:2em; min-height:32px; padding-left:3px; ver=tical-align:middle; margin:4px 3px; display:inline-block">
<select name=3D"entry.206244955_hour" disabled=3D"" id=3D"entry.206244955_ho=ur" aria-label=3D"Hora" style=3D"">
<option value=3D"" style=3D"">
h</option>
 <option value=3D"00" style=3D"">
00</option>
 <option value=3D"01" s=tyle=3D"">
01</option>
 <option value=3D"02" style=3D"">
02</option>
 <option value=3D"03" s=tyle=3D"">
03</option>
<option value=3D"04" style=3D"">
04</option>
 <option value=3D"05" style=3D"">
=05</option>
 <option value=3D"06" style=3D"">
06</option>
 <option value=3D"07" style=3D"">
07</option>
 <option value=3D"08"= style=3D"">
08</option>
 <option value=3D"09" style=3D"">
09</option>
 <option value=3D"10" s=tyle=3D"">
10</option>
<option value=3D"11" style=3D"">
11</option>
 <option value=3D"12" style=3D"">
=12</option>
 <option value=3D"13" selected=3D"" style=3D"">
13</option>
 <option value=3D"14" style=3D"">
14</option>
 <option value=3D"15"= style=3D"">
15</option>
 <option value=3D"16" style=3D"">
16</option>
 <option value=3D"17" s=tyle=3D"">
17</option>
<option value=3D"18" style=3D"">
18</option>
 <option value=3D"19" style=3D"">
=19</option>
 <option value=3D"20" style=3D"">
20</option>
 <option value=3D"21" style=3D"">
21</option>
 <option value=3D"22"= style=3D"">
22</option>
 <option value=3D"23" style=3D"">
23</option>
</select>
 . <select nam=e=3D"entry.206244955_minute" disabled=3D"" id=3D"entry.206244955_minute" ari=a-label=3D"Minuto" style=3D"">
<option value=3D"" style=3D"">
min</option>
 <option value=3D"00" selected=3D"" style=3D"">
00</option>
 <opti=on value=3D"01" style=3D"">
01</option>
 <option value=3D"02" style=3D"">
02</option>
 <option value=3D"03"= style=3D"">
03</option>
 <option value=3D"04" style=3D"">
04</option>
 <option value=3D"05" s=tyle=3D"">
05</option>
<option value=3D"06" style=3D"">
06</option>
 <option value=3D"07" style=3D"">
=07</option>
 <option value=3D"08" style=3D"">
08</option>
 <option value=3D"09" style=3D"">
09</option>
 <option value=3D"10"= style=3D"">
10</option>
 <option value=3D"11" style=3D"">
11</option>
 <option value=3D"12" s=tyle=3D"">
12</option>
<option value=3D"13" style=3D"">
13</option>
 <option value=3D"14" style=3D"">
=14</option>
 <option value=3D"15" style=3D"">
15</option>
 <option value=3D"16" style=3D"">
16</option>
 <option value=3D"17"= style=3D"">
17</option>
 <option value=3D"18" style=3D"">
18</option>
 <option value=3D"19" s=tyle=3D"">
19</option>
<option value=3D"20" style=3D"">
20</option>
 <option value=3D"21" style=3D"">
=21</option>
 <option value=3D"22" style=3D"">
22</option>
 <option value=3D"23" style=3D"">
23</option>
 <option value=3D"24"= style=3D"">
24</option>
 <option value=3D"25" style=3D"">
25</option>
 <option value=3D"26" s=tyle=3D"">
26</option>
<option value=3D"27" style=3D"">
27</option>
 <option value=3D"28" style=3D"">
=28</option>
 <option value=3D"29" style=3D"">
29</option>
 <option value=3D"30" style=3D"">
30</option>
 <option value=3D"31"= style=3D"">
31</option>
 <option value=3D"32" style=3D"">
32</option>
 <option value=3D"33" s=tyle=3D"">
33</option>
<option value=3D"34" style=3D"">
34</option>
 <option value=3D"35" style=3D"">
=35</option>
 <option value=3D"36" style=3D"">
36</option>
 <option value=3D"37" style=3D"">
37</option>
 <option value=3D"38"= style=3D"">
38</option>
 <option value=3D"39" style=3D"">
39</option>
 <option value=3D"40" s=tyle=3D"">
40</option>
<option value=3D"41" style=3D"">
41</option>
 <option value=3D"42" style=3D"">
=42</option>
 <option value=3D"43" style=3D"">
43</option>
 <option value=3D"44" style=3D"">
44</option>
 <option value=3D"45"= style=3D"">
45</option>
 <option value=3D"46" style=3D"">
46</option>
 <option value=3D"47" s=tyle=3D"">
47</option>
<option value=3D"48" style=3D"">
48</option>
 <option value=3D"49" style=3D"">
=49</option>
 <option value=3D"50" style=3D"">
50</option>
 <option value=3D"51" style=3D"">
51</option>
 <option value=3D"52"= style=3D"">
52</option>
 <option value=3D"53" style=3D"">
53</option>
 <option value=3D"54" s=tyle=3D"">
54</option>
<option value=3D"55" style=3D"">
55</option>
 <option value=3D"56" style=3D"">
=56</option>
 <option value=3D"57" style=3D"">
57</option>
 <option value=3D"58" style=3D"">
58</option>
 <option value=3D"59"= style=3D"">
59</option>
</select>
<div class=3D"ss-datetime-box-spacer goog-inline-block" style=3D"height:32px=; vertical-align:middle; display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-select" style=3D"marg=in:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1747608258" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Performance Status ECOG del Paciente <label for=3D"itemView.getDomIdToLabel(=)" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"c=olor:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<select name=3D"entry.1747608258" disabled=3D"" id=3D"entry_17476082=58" aria-label=3D"Performance Status ECOG del Paciente  " style=3D"">
<option= value=3D"" style=3D"">
</option>
 <option value=3D"0" disabled=3D"" selected=3D"" style=3D"">
0</opti=on>
 <option value=3D"1" disabled=3D"" style=3D"">
1</option>
 <option value=3D"2" disabled=3D"" style=3D"">
2</option>
 <option v=alue=3D"3" disabled=3D"" style=3D"">
3</option>
 <option value=3D"4" disabled=3D"" style=3D"">
4</option>
</select>
 <=/div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-scale" style=3D"margin:12px 0; overfl=ow-x:auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1716090865" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Escala Dolor EVA Actual </div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"entry_14216890=35" style=3D"">
<tbody>
<tr aria-hidden=3D"true" style=3D"">
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1421689035_1" style=3D"display:block; padding:0.5=em 0 .5em">
0</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1421689035_2" style=3D"display:block; padding:0.5=em 0 .5em">
1</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1421689035_3" style=3D"display:block; padding:0.5=em 0 .5em">
2</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1421689035_4" style=3D"display:block; padding:0.5=em 0 .5em">
3</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1421689035_5" style=3D"display:block; padding:0.5=em 0 .5em">
4</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1421689035_6" style=3D"display:block; padding:0.5=em 0 .5em">
5</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1421689035_7" style=3D"display:block; padding:0.5=em 0 .5em">
6</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1421689035_8" style=3D"display:block; padding:0.5=em 0 .5em">
7</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1421689035_9" style=3D"display:block; padding:0.5=em 0 .5em">
8</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1421689035_10" style=3D"display:block; padding:0.=5em 0 .5em">
9</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1421689035_11" style=3D"display:block; padding:0.=5em 0 .5em">
10</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr role=3D"radiogroup" aria-label=3D"Escala Dolor EVA Actual  Selecciona un= valor en el rango de 0 a 10." style=3D"">
<td class=3D"ss-scalerow ss-leftlabel" style=3D"text-align:right; color:#666=; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25e=m; padding-left:0">
<div aria-hidden=3D"true" class=3D"aria-todo" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px= solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D="entry.1421689035" disabled=3D"" checked=3D"" value=3D"0" id=3D"group_142168=9035_1" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"0" style=3D"">
</di=v>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px= solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D="entry.1421689035" disabled=3D"" value=3D"1" id=3D"group_1421689035_2" role=3D="radio" class=3D"ss-q-radio" aria-label=3D"1" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px= solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D="entry.1421689035" disabled=3D"" value=3D"2" id=3D"group_1421689035_3" role=3D="radio" class=3D"ss-q-radio" aria-label=3D"2" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px= solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D="entry.1421689035" disabled=3D"" value=3D"3" id=3D"group_1421689035_4" role=3D="radio" class=3D"ss-q-radio" aria-label=3D"3" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px= solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D="entry.1421689035" disabled=3D"" value=3D"4" id=3D"group_1421689035_5" role=3D="radio" class=3D"ss-q-radio" aria-label=3D"4" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px= solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D="entry.1421689035" disabled=3D"" value=3D"5" id=3D"group_1421689035_6" role=3D="radio" class=3D"ss-q-radio" aria-label=3D"5" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px= solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D="entry.1421689035" disabled=3D"" value=3D"6" id=3D"group_1421689035_7" role=3D="radio" class=3D"ss-q-radio" aria-label=3D"6" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px= solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D="entry.1421689035" disabled=3D"" value=3D"7" id=3D"group_1421689035_8" role=3D="radio" class=3D"ss-q-radio" aria-label=3D"7" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px= solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D="entry.1421689035" disabled=3D"" value=3D"8" id=3D"group_1421689035_9" role=3D="radio" class=3D"ss-q-radio" aria-label=3D"8" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px= solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D="entry.1421689035" disabled=3D"" value=3D"9" id=3D"group_1421689035_10" role==3D"radio" class=3D"ss-q-radio" aria-label=3D"9" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px= solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D="entry.1421689035" disabled=3D"" value=3D"10" id=3D"group_1421689035_11" rol=e=3D"radio" class=3D"ss-q-radio" aria-label=3D"10" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow ss-rightlabel" aria-hidden=3D"true" style=3D"text-a=lign: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"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-scale" style=3D"margin:12px 0; overfl=ow-x:auto">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_2064050596" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Escala Dolor EVA M=C3=A1ximo </div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"entry_12447075=12" style=3D"">
<tbody>
<tr aria-hidden=3D"true" style=3D"">
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1244707512_1" style=3D"display:block; padding:0.5=em 0 .5em">
0</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1244707512_2" style=3D"display:block; padding:0.5=em 0 .5em">
1</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1244707512_3" style=3D"display:block; padding:0.5=em 0 .5em">
2</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1244707512_4" style=3D"display:block; padding:0.5=em 0 .5em">
3</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1244707512_5" style=3D"display:block; padding:0.5=em 0 .5em">
4</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1244707512_6" style=3D"display:block; padding:0.5=em 0 .5em">
5</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1244707512_7" style=3D"display:block; padding:0.5=em 0 .5em">
6</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
<label class=3D"ss=-scalenumber" for=3D"group_1244707512_8" style=3D"display:block; padding:0.5=em 0 .5em">
7</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
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8</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
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9</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
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10</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
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</div>
</td>
<td class=3D"ss-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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<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px= solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
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</div>
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</td>
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9</label>
</td>
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</td>
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</td>
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<td class=3D"ss-scalerow ss-leftlabel" style=3D"text-align:right; color:#666=; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25e=m; padding-left:0">
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<label class=3D"ss-q-item-label" for=3D"entry_1255665248" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
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<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"c=olor:#c43b1d">
*</span>
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<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; margin:.1em 0 .25em 0; color:#666">
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Mantener tro medico analgesico, se realiza formula medica de ananlgesicos pa=ra presentar en su isapte, solicita licencia medica la cual se realiza por 1= mes.</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-paragraph-text" style=3D"margin:12px 0=">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
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<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Medicamentos Indicados </div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; margin:.1em 0 .25em 0; color:#666">
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<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee; max-wi=dth:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:=#545454; width:70%">
Tramadol gotas 5 gotas vada 6 horas y sos, paracetamol 1gr diario en caso do=lor kntenso, pregabalina 150 mg cada 8 horas, ondasetron tabletas cada 12 ho=ras, mantener suplementaciin hormonal, mantener solicirud de apoyo nutricion=al y psicologia.</div>
</div>
</div>
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Fecha aproximada del Pr=C3=B3ximo Control con usted </div>
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1937</option>
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1939</option>
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1940</option>
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1942</option>
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1943</option>
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1946</option>
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1953</option>
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1963</option>
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1966</option>
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1975</option>
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1986</option>
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1987</option>
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1990</option>
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1992</option>
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1993</option>
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1995</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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2005</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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2013</option>
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2014</option>
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2020</option>
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2021</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 class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Tratamiento Realizado (si corresponde) </div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; margin:.1em 0 .25em 0; color:#666">
</div>
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</div>
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<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-checkbox" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
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<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-t=op:.83em; margin-bottom:.83em">
Derivaci=C3=B3n a otro Prestador Domiciliario </div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck; 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 o=tro prestador del equipo</div>
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ENFERMERA</span>
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TENS</span>
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<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"dis=play:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disable=d=3D"" checked=3D"" value=3D"NUTRICIONISTA" id=3D"group_503039759_3" role=3D="checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
NUTRICIONISTA</span>
 </label>
</li=>
<li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-=bottom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"dis=play:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disable=d=3D"" value=3D"KINESIOLOGO" id=3D"group_503039759_4" role=3D"checkbox" clas=s=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
KINESIOLOGO</span>
 </label>
</li>
<=li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bo=ttom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"dis=play:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disable=d=3D"" checked=3D"" value=3D"PSICOLOGO" id=3D"group_503039759_5" role=3D"che=ckbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
PSICOLOGO</span>
 </label>
</li>
</u=l>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style=3D="margin:12px 0; max-width:100%">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:mi=ddle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-to=p:.83em; margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"ss-image" title=3D"" alt=3D"Im=agen sin t=C3=ADtulo" style=3D"width:78px; outline:none" src=3D"https://lh5.=googleusercontent.com/Bpur5zPteyG-bXtM-WNRuiLwTi8myvetX7lBkdjzbnQyqUlGcuv84z=mWyU3x0Ua2-_WXX9PiJ2cMBOO0zhG2nHX7tXXPHH6_X8UTG8MZzIBwxETkF0a8JyZtuxSL">
</di=v>
</div>
</div>
</div>
<br>
</form>
</div>
</div>
</td>
</tr>
<tr height=3D"24px">
</tr>
</tbody>
</table>
</div>
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%" r=ole=3D"presentation" style=3D"max-width:672px; min-width:154px">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"=color:#424242; font-size:13px">
Crear tu propio Formulario de Google</a>
</td>
=</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</blockquote>
</body>
</html>
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