<div dir=3D"ltr">
Junta con saludar env=C3=ADo registro de atenci=C3=B3n.<br clear=3D"all">
<div>
<div dir=3D"ltr" class=3D"gmail_signature" data-smartmail=3D"gmail_signature">
<div dir=3D"ltr">
<div>
<div dir=3D"ltr">
<div style=3D"text-align:center">
<font size=3D"4" color=3D"#000000">
<b>
<i>
Gerardo Burgos Contreras</i>
</b>
</font>
</div>
<div style=3D"text-align:center">
<font size==3D"4" color=3D"#000000">
<b>
<i>
17.561.534-2</i>
</b>
</font>
</div>
<div style==3D"text-align:center">
<font size=3D"4" color=3D"#000000">
<b>
<i>
Kinesi=C3==B3logo</i>
</b>
</font>
</div>
<div style=3D"text-align:center">
<br>
</div>
</div>
</div>
</div>
</div>
</div>
<br>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class=3D"gmail_attr">
---------- Forwarded message ---------<br>
From: <strong class=3D"gmail_sendername" dir=3D"auto">
Formularios de Google</strong>
 <span dir=3D"ltr">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: mar., 19 mar. 2019 a las 12:03<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:klgo.gerardoburgos.c@gmail.com">
klgo.gerardoburgos.c@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_5914914448485332760ss-form-container">
<div class=3D"m_5914914448485332760ss-form-heading">
<h1 class=3D"m_5914914448485332760ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_5914914448485332760ss-form-desc m_5914914448485332760ss-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_5914914448485332760ss-form">
<form method=3D"GET" id=3D"m_5914914448485332760ss-form" target=3D"_blank">
<br>
<div class=3D"m_5914914448485332760ss-form-question m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-item-required m_5914914448485332760ss-text" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760emailAddress">
<div class=3D"m_5914914448485332760ss-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_5914914448485332760emailAddress">
</label>
<span class=3D"m_5914914448485332760ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_5914914448485332760ss-q-text m_5914914448485332760ss-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:klgo.gerardoburgos.c@gmail.com" target=3D"_blank">
klgo.gerardoburgos.c@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_5914914448485332760ss-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_5914914448485332760ss-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_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_5914914448485332760ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_5914914448485332760ss-page-description m_5914914448485332760ss-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_5914914448485332760ss-form-question m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-item-required m_5914914448485332760ss-text" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_579114469">
<div class=3D"m_5914914448485332760ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_5914914448485332760itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5914914448485332760ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5914914448485332760ss-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%">
Gerardo Burgos</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5914914448485332760ss-form-question m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-item-required m_5914914448485332760ss-text" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_1276273985">
<div class=3D"m_5914914448485332760ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_5914914448485332760itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5914914448485332760ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-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_5914914448485332760ss-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%">
17561534-2</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5914914448485332760ss-form-question m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-item-required m_5914914448485332760ss-select" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_133691676">
<div class=3D"m_5914914448485332760ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_5914914448485332760itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5914914448485332760ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-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_5914914448485332760entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled selected>
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_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_5914914448485332760ss-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_5914914448485332760ss-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_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_5914914448485332760ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_5914914448485332760ss-page-description m_5914914448485332760ss-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_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_5914914448485332760ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_5914914448485332760ss-section-description m_5914914448485332760ss-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_5914914448485332760ss-form-question m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-item-required m_5914914448485332760ss-text" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_823811303">
<div class=3D"m_5914914448485332760ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_5914914448485332760itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5914914448485332760ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-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_5914914448485332760ss-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%">
4302990-8</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5914914448485332760ss-form-question m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-item-required m_5914914448485332760ss-text" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_1959365839">
<div class=3D"m_5914914448485332760ss-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_5914914448485332760itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5914914448485332760ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5914914448485332760ss-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%">
Pedro Caro</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5914914448485332760ss-form-question m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-item-required m_5914914448485332760ss-select" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_545002227">
<div class=3D"m_5914914448485332760ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_5914914448485332760itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5914914448485332760ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-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_5914914448485332760entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled selected>
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_5914914448485332760ss-form-question m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-item-required m_5914914448485332760ss-text" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_1900161356">
<div class=3D"m_5914914448485332760ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_5914914448485332760itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5914914448485332760ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5914914448485332760ss-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%">
La Uni=C3=B3n</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5914914448485332760ss-form-question m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-item-required m_5914914448485332760ss-text" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_1298871758">
<div class=3D"m_5914914448485332760ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_5914914448485332760itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5914914448485332760ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5914914448485332760ss-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%">
La Uni=C3=B3n</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_5914914448485332760ss-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_5914914448485332760ss-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_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_5914914448485332760ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_5914914448485332760ss-page-description m_5914914448485332760ss-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_5914914448485332760ss-form-question m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-item-required m_5914914448485332760ss-radio" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-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_5914914448485332760ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_5914914448485332760itemView.getDomIdToLabel()">
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<span class=3D"m_5914914448485332760ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_5914914448485332760ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
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<label>
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<span class=3D"m_5914914448485332760ss-choice-label">
Domicilio</span>
</label>
</li>
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<label>
<span class=3D"m_5914914448485332760ss-choice-item-control m_5914914448485332760goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_5914914448485332760group_1222378237_2" class=3D"m_5914914448485332760ss-q-radio">
</span>
<span class=3D"m_5914914448485332760ss-choice-label">
Ambulatorio</span>
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</li>
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</div>
</div>
<br>
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<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-item-required m_5914914448485332760ss-date" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_1705849412">
<div class=3D"m_5914914448485332760ss-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_5914914448485332760itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5914914448485332760ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5914914448485332760ss-q-date">
<div class=3D"m_5914914448485332760ss-datetime-box m_5914914448485332760goog-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>
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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>
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=20<select name=3D"entry.1705849412_year" disabled id=3D"m_5914914448485332760entry.1705849412_year">
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A=C3=B1o</option>
<option value=3D"1896">
1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
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2019</option>
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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_5914914448485332760ss-form-question m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-item-required m_5914914448485332760ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_206244955">
<div class=3D"m_5914914448485332760ss-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_5914914448485332760itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5914914448485332760ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5914914448485332760ss-q-time">
<div class=3D"m_5914914448485332760ss-datetime-box m_5914914448485332760goog-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_5914914448485332760entry.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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08</option>
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09</option>
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10</option>
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11</option>
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12</option>
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<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_1716090865">
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Escala Dolor EVA Actual</div>
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0</label>
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<label class=3D"m_5914914448485332760ss-scalenumber" for=3D"m_5914914448485332760group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
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2</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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<label class=3D"m_5914914448485332760ss-scalenumber" for=3D"m_5914914448485332760group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
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8</label>
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9</label>
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10</label>
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</div>
</div>
<br>
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<div class=3D"m_5914914448485332760ss-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_5914914448485332760ss-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_5914914448485332760ss-q-help m_5914914448485332760ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
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</td>
<td class=3D"m_5914914448485332760ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5914914448485332760ss-scalenumber" for=3D"m_5914914448485332760group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_5914914448485332760ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5914914448485332760ss-scalenumber" for=3D"m_5914914448485332760group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
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<label class=3D"m_5914914448485332760ss-scalenumber" for=3D"m_5914914448485332760group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
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<label class=3D"m_5914914448485332760ss-scalenumber" for=3D"m_5914914448485332760group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
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<label class=3D"m_5914914448485332760ss-scalenumber" for=3D"m_5914914448485332760group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
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<label class=3D"m_5914914448485332760ss-scalenumber" for=3D"m_5914914448485332760group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_5914914448485332760ss-scalenumber" for=3D"m_5914914448485332760group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
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<label class=3D"m_5914914448485332760ss-scalenumber" for=3D"m_5914914448485332760group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label class=3D"m_5914914448485332760ss-scalenumber" for=3D"m_5914914448485332760group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label class=3D"m_5914914448485332760ss-scalenumber" for=3D"m_5914914448485332760group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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<label class=3D"m_5914914448485332760ss-scalenumber" for=3D"m_5914914448485332760group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_5914914448485332760ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_5914914448485332760ss-scalerow m_5914914448485332760ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_5914914448485332760aria-todo">
</div>
</td>
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Escala Dolor EVA M=C3=ADnimo</div>
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0</label>
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1</label>
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2</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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</td>
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<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_2140974612">
<div class=3D"m_5914914448485332760ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Anamnesis/Evoluci=C3=B3n<label for=3D"m_5914914448485332760itemView.getDomIdToLabel()">
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<span class=3D"m_5914914448485332760ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
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</div>
</label>
<div class=3D"m_5914914448485332760ss-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%">
Usuario en BEG, un poco desanimado con dolor por ca=C3=ADda sufrida el d=C3=ADa domingo 17/03/2019  en casa de su hijo en Rio Bueno, donde se golpeo en zona postero lateral derecha de espalda que le produjo un hematoma significante y tambi=C3=A9n en parrilla costal derecha con presencia de mucho dolor al sentarse,acostarse y para dormir EVA 4 m=C3=A1ximo que sinti=C3=B3 el d=C3=ADa de la ca=C3=ADda.Usuario relata de igual manera que no paso muy buena noche donde durmi=C3==B3 poco y con mucha molestia nocturna por ca=C3=ADda sufrida por lo mismo se encuentra somnoliento a la hora de terapia. </div>
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<div class=3D"m_5914914448485332760ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
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</div>
</label>
<div class=3D"m_5914914448485332760ss-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%">
Usuario con mismas caracter=C3=ADsticas pasadas solo que esta vez sufre caida lo que le produce un hematoma considerable en zona postero-lateral de espalda.P/A: 127/80Sao2: 99%FC: 112Examen pulmonar: MP + , Sin ruidos agregados (SRA)Se comienza terapia con ejercicios decubito supino en cama- 15 repeticiones de flexi=C3=B3n y extensi=C3=B3n de cadera por cada una- 15 repeticiones de flexi=C3=B3n y extensi=C3=B3n de rodilla por cada una- 15 repeticiones de elevaci=C3=B3n de cadera=20- 15 repeticiones de abducci=C3=B3n y adduci=C3=B3n de cadera- 15 de fortalecimiento de m=C3=BAsculos abductores de cadera (con banda el=C3=A1stica con m=C3=ADnima resistencia)- 15 repeticiones de fortalecimiento de isquitibiales- 3 series de 15 repeticiones de movilidad de pies en flexo-extensi=C3=B3n por cada 3 ejercicios una serie de pie- 15 repeticiones de ABD-ADD-FLEX-EXT de hombro peso libre=20- Sedente borde cama (SBC) se trabajo movilidad de extremidad inferiores con 15 repeticionesTodos los ejercicios realizados activos con m=C3=ADnima asistencia para mayor eficacia.Se realizo marcha donde se traslado de primer piso a su habitaci=C3=B3n con ayuda de hijo y profesional y tambi=C3=A9n se realizo subida de escala.Usuario tolera bien terapia no presenta dolor al realizar los ejercicios relata no sentir cansancio pero si comenta que que en algunos de ellos les cuesta por falta de fuerza. </div>
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</div>
<br>
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<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-item-required m_5914914448485332760ss-text" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_1690694733">
<div class=3D"m_5914914448485332760ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_5914914448485332760itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5914914448485332760ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5914914448485332760ss-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%">
CA de prostata</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5914914448485332760ss-form-question m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-item-required m_5914914448485332760ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_1255665248">
<div class=3D"m_5914914448485332760ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_5914914448485332760itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5914914448485332760ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5914914448485332760ss-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%">
Continuar con terapias en casa realizar los ejercicios asignados 2 veces al d=C3=ADa m=C3=A1ximo y m=C3=ADnimo 1 vez al d=C3=ADa, para que en la pr=C3=B3xima sesi=C3=B3n evaluar avance y continuar con mas series y repeticiones.</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5914914448485332760ss-form-question m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_1648939075">
<div class=3D"m_5914914448485332760ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5914914448485332760ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5914914448485332760ss-form-question m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-date" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-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_5914914448485332760ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5914914448485332760ss-q-date">
<div class=3D"m_5914914448485332760ss-datetime-box m_5914914448485332760goog-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>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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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>
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A=C3=B1o</option>
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1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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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>
 <option value==3D"2042">
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_5914914448485332760ss-form-question m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-text" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_74766472">
<div class=3D"m_5914914448485332760ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5914914448485332760ss-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%">
Terapia F=C3=ADsica.</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5914914448485332760ss-form-question m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5914914448485332760ss-q-item-label" for=3D"m_5914914448485332760entry_1219705969">
<div class=3D"m_5914914448485332760ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_5914914448485332760ss-q-help m_5914914448485332760ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
</label>
<ul class=3D"m_5914914448485332760ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
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<label>
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<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"ENFERMERA" id=3D"m_5914914448485332760group_503039759_1" class=3D"m_5914914448485332760ss-q-checkbox">
</span>
<span class=3D"m_5914914448485332760ss-choice-label">
ENFERMERA</span>
</label>
</li>
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<label>
<span class=3D"m_5914914448485332760ss-choice-item-control m_5914914448485332760goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_5914914448485332760group_503039759_2" class=3D"m_5914914448485332760ss-q-checkbox">
</span>
<span class=3D"m_5914914448485332760ss-choice-label">
TENS</span>
</label>
</li>
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<label>
<span class=3D"m_5914914448485332760ss-choice-item-control m_5914914448485332760goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id==3D"m_5914914448485332760group_503039759_3" class=3D"m_5914914448485332760ss-q-checkbox">
</span>
<span class=3D"m_5914914448485332760ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
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<label>
<span class=3D"m_5914914448485332760ss-choice-item-control m_5914914448485332760goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"KINESIOLOGO" id=3D"m_5914914448485332760group_503039759_4" class=3D"m_5914914448485332760ss-q-checkbox">
</span>
<span class=3D"m_5914914448485332760ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
 <li class=3D"m_5914914448485332760ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_5914914448485332760ss-choice-item-control m_5914914448485332760goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"PSICOLOGO" id=3D"m_5914914448485332760group_503039759_5" class=3D"m_5914914448485332760ss-q-checkbox">
</span>
<span class=3D"m_5914914448485332760ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_5914914448485332760errorbox-good">
<div dir=3D"auto" class=3D"m_5914914448485332760ss-item m_5914914448485332760ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_5914914448485332760ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_5914914448485332760ss-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_5914914448485332760ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</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" style=3D"max-width:672px;min-width:154px" width=3D"100%">
<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" target=3D"_blank">
Crea tu propio formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
<div id=3D"DAB4FAD8-2DD7-40BB-A1B8-4E2AA1F9FDF2">
<br>
 <table style=3D"border-top:1px solid #d3d4de">
	<tr>
      <td style=3D"width:55px;padding-top:18px">
<a href=3D"https://www.avast.com/sig-email?utm_medium=3Demail&amp;utm_source=3Dlink&amp;utm_campaign==3Dsig-email&amp;utm_content=3Dwebmail" target=3D"_blank">
<img src=3D"https://ipmcdn.avast.com/images/icons/icon-envelope-tick-round-orange-animated-no-repeat-v1.gif" alt=3D"" width=3D"46" height=3D"29" style=3D"width: 46px; height: 29px;">
</a>
</td>
		<td style=3D"width:470px;padding-top:17px;color:#41424e;font-size:13px;font-family:Arial,Helvetica,sans-serif;line-height:18px">
Libre de virus. <a href=3D"https://www.avast.com/sig-email?utm_medium=3Demail&amp;utm_source=3Dlink&amp;utm_campaign=3Dsig-email&amp;utm_content=3Dwebmail" target=3D"_blank" style=3D"color:#4453ea">
www.avast.com</a>
 		</td>
	</tr>
</table>
<a href=3D"#DAB4FAD8-2DD7-40BB-A1B8-4E2AA1F9FDF2" width=3D"1" height=3D"1">
</a>
</div>
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