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       =20        </div>
<div id=3D"yahoo_quoted_5227316624" class=3D"yahoo_quoted">
            <div style=3D"font-family:'Helvetica Neue', Helvetica, Arial, sans-serif;font-size:13px;color:#26282a;">
               =20                <div>
                    On Tuesday, April 2, 2019, 10:37:59 PM GMT-3, Formularios de Google &lt;forms-receipts-noreply@google.com&gt; wrote:                </div>
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<img alt=3D"Formularios de Google" style=3D"display:inline-block;margin:0;vertical-align:middle;" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png" width=3D"143px" height=3D"26px">
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<div style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px;" align=3D"center">
<table style=3D"background-color:#fff;" role=3D"presentation" width=3D"100%" cellspacing=3D"0" cellpadding=3D"0" align=3D"center">
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<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700;">
Gracias por llenar <a rel=3D"nofollow" target=3D"_blank" href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
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Estas son tus respuestas:</div>
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<div class=3D"yiv8970500305ss-form-container" style=3D"">
<div class=3D"yiv8970500305ss-form-heading" style=3D"">
<h1 class=3D"yiv8970500305ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0;">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"yiv8970500305ss-form-desc yiv8970500305ss-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>
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<div class=3D"yiv8970500305ss-form" style=3D"">
<form target=3D"_blank" onsubmit=3D"return window.theMainWindow.showFormWarning(this)" method=3D"GET" id=3D"yiv8970500305ss-form" style=3D"">
<br>
<div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item yiv8970500305ss-item-required yiv8970500305ss-text" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for==3D"emailAddress" style=3D"">
<div class=3D"yiv8970500305ss-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"emailAddress" style=3D"">
</label>
<span class=3D"yiv8970500305ss-required-asterisk" style=3D"color:#c43b1d;">
*</span>
</div>
</label>
<div class=3D"yiv8970500305ss-q-text yiv8970500305ss-printable-text-line" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
bonoedge2000@yahoo.com</div>
</div>
</div>
</div>
<div class=3D"yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item  yiv8970500305ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%;position:relative;">
<div class==3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class=3D"yiv8970500305ss-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"yiv8970500305ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none;" alt=3D"Imagen sin t=C3=ADtulo">
</div>
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</div>
</div>
<br>
 <div class=3D"yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item  yiv8970500305ss-page-break" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class=3D"yiv8970500305ss-page-title" style=3D"margin:2em -0.4em 0;padding:0.4em;background-color:#eee;">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"yiv8970500305ss-page-description yiv8970500305ss-no-ignore-whitespace" 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"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item yiv8970500305ss-item-required yiv8970500305ss-text" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_579114469" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Primer Nombre y Apellido Paterno<label style=3D"">
</label>
<span class=3D"yiv8970500305ss-required-asterisk" style=3D"color:#c43b1d;">
*</span>
</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"yiv8970500305ss-q-text" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Jos=C3=A9 Ramos</div>
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 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item yiv8970500305ss-item-required yiv8970500305ss-text" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_1276273985" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
RUT<label style=3D"">
</label>
<span class=3D"yiv8970500305ss-required-asterisk" style=3D"color:#c43b1d;">
*</span>
</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" 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"yiv8970500305ss-q-text" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
12962980-0</div>
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</div>
</div>
<br>
 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item yiv8970500305ss-item-required yiv8970500305ss-select" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_133691676" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Tipo<label style=3D"">
</label>
<span class=3D"yiv8970500305ss-required-asterisk" style=3D"color:#c43b1d;">
*</span>
</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" 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=3D"" id=3D"yiv8970500305entry_133691676" style=3D"">
<option value=3D"" style=3D"">
</option>
<option value=3D"MEDICO" disabled=3D"" selected=3D"" style=3D"">
MEDICO</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"">
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled=3D"" style=3D"">
PSICOLOGO</option>
 <option value=3D"NUTRICIONISTA" disabled=3D"" style=3D"">
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item  yiv8970500305ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%;position:relative;">
<div class==3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class=3D"yiv8970500305ss-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"yiv8970500305ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none;" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item  yiv8970500305ss-page-break" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class=3D"yiv8970500305ss-page-title" style=3D"margin:2em -0.4em 0;padding:0.4em;background-color:#eee;">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"yiv8970500305ss-page-description yiv8970500305ss-no-ignore-whitespace" 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"yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item  yiv8970500305ss-section-header" style==3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class=3D"yiv8970500305ss-section-title" style=3D"background-color:#eee;padding:0.4em;margin:2em -0.4em 0;">
Datos Personales del Paciente</h2>
<div class=3D"yiv8970500305ss-section-description yiv8970500305ss-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"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item yiv8970500305ss-item-required yiv8970500305ss-text" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_823811303" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Ingrese el Rut del Paciente<label style=3D"">
</label>
<span class=3D"yiv8970500305ss-required-asterisk" style=3D"color:#c43b1d;">
*</span>
</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" 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"yiv8970500305ss-q-text" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
8647701-7</div>
</div>
</div>
</div>
<br>
 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item yiv8970500305ss-item-required yiv8970500305ss-text" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_1959365839" style=3D"">
<div class=3D"yiv8970500305ss-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 style=3D"">
</label>
<span class=3D"yiv8970500305ss-required-asterisk" style=3D"color:#c43b1d;">
*</span>
</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"yiv8970500305ss-q-text" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Marta Lopez Hernandez</div>
</div>
</div>
</div>
<br>
 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item yiv8970500305ss-item-required yiv8970500305ss-select" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_545002227" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Previsi=C3=B3n<label style=3D"">
</label>
<span class=3D"yiv8970500305ss-required-asterisk" style=3D"color:#c43b1d;">
*</span>
</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<select name=3D"entry.545002227" disabled=3D"" id=3D"yiv8970500305entry_545002227" style=3D"">
<option value=3D"" style=3D"">
</option>
<option value=3D"BANMEDICA" disabled=3D"" style=3D"">
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled=3D"" style=3D"">
CAPREDENA</option>
 <option value=3D"COLMENA" disabled=3D"" style=3D"">
COLMENA</option>
 <option value=3D"CONSALUD" disabled=3D"" style=3D"">
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled=3D"" style=3D"">
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled=3D"" style=3D"">
DIPRECA</option>
 <option value=3D"FONASA" disabled=3D"" style=3D"">
FONASA</option>
 <option value=3D"FUNDACION" disabled=3D"" style=3D"">
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled=3D"" selected=3D"" style=3D"">
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled=3D"" style=3D"">
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled=3D"" style=3D"">
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled=3D"" style=3D"">
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item yiv8970500305ss-item-required yiv8970500305ss-text" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_1900161356" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Ciudad<label style=3D"">
</label>
<span class=3D"yiv8970500305ss-required-asterisk" style=3D"color:#c43b1d;">
*</span>
</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"yiv8970500305ss-q-text" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Chimbarongo</div>
</div>
</div>
</div>
<br>
 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item yiv8970500305ss-item-required yiv8970500305ss-text" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_1298871758" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Comuna<label style=3D"">
</label>
<span class=3D"yiv8970500305ss-required-asterisk" style=3D"color:#c43b1d;">
*</span>
</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"yiv8970500305ss-q-text" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Chimbarongo</div>
</div>
</div>
</div>
<br>
 <div class=3D"yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item  yiv8970500305ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%;position:relative;">
<div class==3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class=3D"yiv8970500305ss-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"yiv8970500305ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none;" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item  yiv8970500305ss-page-break" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class=3D"yiv8970500305ss-page-title" style=3D"margin:2em -0.4em 0;padding:0.4em;background-color:#eee;">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"yiv8970500305ss-page-description yiv8970500305ss-no-ignore-whitespace" 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"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item yiv8970500305ss-item-required yiv8970500305ss-radio" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_2073233714" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Tipo de Atenci=C3=B3n<label style=3D"">
</label>
<span class=3D"yiv8970500305ss-required-asterisk" style=3D"color:#c43b1d;">
*</span>
</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<ul class=3D"yiv8970500305ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0;">
<li class=3D"yiv8970500305ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em;">
<label>
<span class=3D"yiv8970500305ss-choice-item-control yiv8970500305goog-inline-block" style=3D"position:relative;display:inline-block;">
<input type=3D"radio" name=3D"entry.1222378237" disabled=3D"" checked=3D"" value=3D"Domicilio" id=3D"yiv8970500305group_1222378237_1" class=3D"yiv8970500305ss-q-radio" style=3D"">
</span>
<span class=3D"yiv8970500305ss-choice-label" style=3D"">
Domicilio</span>
</label>
</li>
 <li class=3D"yiv8970500305ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em;">
<label>
<span class=3D"yiv8970500305ss-choice-item-control yiv8970500305goog-inline-block" style=3D"position:relative;display:inline-block;">
<input type=3D"radio" name=3D"entry.1222378237" disabled=3D"" value=3D"Ambulatorio" id=3D"yiv8970500305group_1222378237_2" class=3D"yiv8970500305ss-q-radio" style=3D"">
</span>
<span class=3D"yiv8970500305ss-choice-label" style=3D"">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item yiv8970500305ss-item-required yiv8970500305ss-date" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_1705849412" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Fecha de la Atenci=C3=B3n<label style=3D"">
</label>
<span class=3D"yiv8970500305ss-required-asterisk" style=3D"color:#c43b1d;">
*</span>
</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"yiv8970500305ss-q-date" style=3D"">
<div class=3D"yiv8970500305ss-datetime-box yiv8970500305goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;position:relative;display:inline-block;">
 <select name==3D"entry.1705849412_month" disabled=3D"" class=3D"yiv8970500305ss-month-dropdown" id=3D"yiv8970500305entry.1705849412_month" style=3D"">
<option value=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" selected=3D"" style=3D"">
abril</option>
 <option value=3D"5" style=3D"">
mayo</option>
 <option value=3D"6" style=3D"">
junio</option>
 <option value=3D"7" style=3D"">
julio</option>
 <option value=3D"8" style=3D"">
agosto</option>
 <option value=3D"9" style=3D"">
septiembre</option>
 <option value==3D"10" style=3D"">
octubre</option>
 <option value=3D"11" style=3D"">
noviembre</option>
 <option value=3D"12" style=3D"">
diciembre</option>
</select>
   <select name=3D"entry.1705849412_day" disabled=3D"" class=3D"yiv8970500305ss-day-dropdown" id=3D"yiv8970500305entry.1705849412_day" style=3D"">
<option value=3D"" style=3D"">
D=C3=ADa</option>
<option value=3D"1" style=3D"">
1</option>
 <option value=3D"2" selected=3D"" 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" style=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" 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" 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>
 <option value=3D"24" style=3D"">
24</option>
 <option value=3D"25" style=3D"">
25</option>
 <option value=3D"26" 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" style=3D"">
30</option>
 <option value=3D"31" style=3D"">
31</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled=3D"" id=3D"yiv8970500305entry.1705849412_year" style=3D"">
<option value=3D"" style=3D"">
A=C3=B1o</option>
<option value=3D"1896" style=3D"">
1896</option>
 <option value=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"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item yiv8970500305ss-item-required yiv8970500305ss-time" style=3D"margin:12px 0;font:inherit;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_206244955" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Hora de la Atenci=C3=B3n<label style=3D"">
</label>
<span class=3D"yiv8970500305ss-required-asterisk" style=3D"color:#c43b1d;">
*</span>
</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"yiv8970500305ss-q-time" style=3D"">
<div class=3D"yiv8970500305ss-datetime-box yiv8970500305goog-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;position:relative;display:inline-block;">
<select name=3D"entry.206244955_hour" disabled=3D"" id=3D"yiv8970500305entry.206244955_hour" style=3D"">
<option value=3D"" style=3D"">
h</option>
<option value=3D"00" style=3D"">
00</option>
 <option 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" style=3D"">
05</option>
 <option value=3D"06" style=3D"">
06</option>
 <option value=3D"07" style=3D"">
07</option>
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08</option>
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13</option>
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42</option>
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51</option>
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52</option>
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55</option>
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56</option>
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58</option>
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59</option>
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<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_1747608258" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Performance Status ECOG del Paciente<label style=3D"">
</label>
<span class=3D"yiv8970500305ss-required-asterisk" style=3D"color:#c43b1d;">
*</span>
</div>
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</option>
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0</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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</div>
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<br>
 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item  yiv8970500305ss-scale" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_1716090865" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Escala Dolor EVA Actual</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
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<tr style=3D"">
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</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1421689035_1" style==3D"display:block;padding:0.5em 0 .5em;">
0</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_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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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em;">
5</label>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em;">
6</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em;">
7</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em;">
8</label>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em;">
9</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em;">
10</label>
</td>
<td class=3D"yiv8970500305ss-scalenumbers" style=3D"text-align:center;">
</td>
</tr>
<tr style=3D"">
<td class=3D"yiv8970500305ss-scalerow yiv8970500305ss-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"yiv8970500305aria-todo" style=3D"">
</div>
</td>
<td class=3D"yiv8970500305ss-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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<div class=3D"yiv8970500305ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entry.1421689035" disabled=3D"" value=3D"5" id=3D"yiv8970500305group_1421689035_6" class=3D"yiv8970500305ss-q-radio" style=3D"">
</div>
</td>
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<div class=3D"yiv8970500305ss-scalerow-fieldcell" style=3D"">
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</div>
</td>
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<div class=3D"yiv8970500305ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entry.1421689035" disabled=3D"" value=3D"9" id=3D"yiv8970500305group_1421689035_10" class=3D"yiv8970500305ss-q-radio" style=3D"">
</div>
</td>
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<div class=3D"yiv8970500305ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entry.1421689035" disabled=3D"" value=3D"10" id=3D"yiv8970500305group_1421689035_11" class=3D"yiv8970500305ss-q-radio" style=3D"">
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</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item  yiv8970500305ss-scale" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_2064050596" style=3D"">
<div class=3D"yiv8970500305ss-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"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<table id=3D"yiv8970500305entry_1244707512" style=3D"" cellspacing=3D"0" cellpadding=3D"5" border=3D"0">
<tbody>
<tr style=3D"">
<td class=3D"yiv8970500305ss-scalenumbers" style=3D"text-align:center;">
</td>
<td class=3D"yiv8970500305ss-scalenumbers" style=3D"text-align:center;">
<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1244707512_1" style==3D"display:block;padding:0.5em 0 .5em;">
0</label>
</td>
 <td class=3D"yiv8970500305ss-scalenumbers" style=3D"text-align:center;">
<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em;">
1</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em;">
2</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em;">
3</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em;">
4</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em;">
5</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em;">
6</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em;">
7</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em;">
8</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em;">
9</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em;">
10</label>
</td>
<td class=3D"yiv8970500305ss-scalenumbers" style=3D"text-align:center;">
</td>
</tr>
<tr style=3D"">
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<div class=3D"yiv8970500305aria-todo" style=3D"">
</div>
</td>
<td class=3D"yiv8970500305ss-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>
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<br>
 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item  yiv8970500305ss-scale" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_2000523015" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Escala Dolor EVA M=C3=ADnimo</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
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</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_853118630_1" style==3D"display:block;padding:0.5em 0 .5em;">
0</label>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_853118630_2" style=3D"display:block;padding:0.5em 0 .5em;">
1</label>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_853118630_3" style=3D"display:block;padding:0.5em 0 .5em;">
2</label>
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3</label>
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4</label>
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5</label>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_853118630_7" style=3D"display:block;padding:0.5em 0 .5em;">
6</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_853118630_8" style=3D"display:block;padding:0.5em 0 .5em;">
7</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_853118630_9" style=3D"display:block;padding:0.5em 0 .5em;">
8</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_853118630_10" style=3D"display:block;padding:0.5em 0 .5em;">
9</label>
</td>
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<label class=3D"yiv8970500305ss-scalenumber" for=3D"group_853118630_11" style=3D"display:block;padding:0.5em 0 .5em;">
10</label>
</td>
<td class=3D"yiv8970500305ss-scalenumbers" style=3D"text-align:center;">
</td>
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<div class=3D"yiv8970500305aria-todo" style=3D"">
</div>
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</div>
</td>
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<input type=3D"radio" name=3D"entry.853118630" disabled=3D"" value=3D"8" id=3D"yiv8970500305group_853118630_9" class=3D"yiv8970500305ss-q-radio" style=3D"">
</div>
</td>
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<div class=3D"yiv8970500305ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entry.853118630" disabled=3D"" value=3D"9" id=3D"yiv8970500305group_853118630_10" class=3D"yiv8970500305ss-q-radio" style=3D"">
</div>
</td>
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<div class=3D"yiv8970500305ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entry.853118630" disabled=3D"" value=3D"10" id=3D"yiv8970500305group_853118630_11" class=3D"yiv8970500305ss-q-radio" style=3D"">
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</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
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 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item yiv8970500305ss-item-required yiv8970500305ss-paragraph-text" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_2140974612" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Anamnesis/Evoluci=C3=B3n<label style=3D"">
</label>
<span class=3D"yiv8970500305ss-required-asterisk" style=3D"color:#c43b1d;">
*</span>
</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"yiv8970500305ss-q-text" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Paciente de 61 a=C3=B1os de sexo femenino, con diagn=C3=B3stico de C=C3=A1ncer de Mama avanzado, con met=C3=A1stasis =C3=B3seas. Sufri=C3=B3 un TEP masivo, por lo cual estuvo hospitalizada en Cl=C3=ADnica Bicentenario desde 28/02/2019 hasta 21/03/2019, con buena evoluci=C3=B3n cl=C3=ADnica, recuperandose de su TEP. Actualmente con manejo paliativo del dolor, y oxigenoterapia:  2lts x minuto</div>
</div>
</div>
</div>
<br>
 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item yiv8970500305ss-item-required yiv8970500305ss-paragraph-text" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_824006088" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Examen F=C3=ADsico<label style=3D"">
</label>
<span class=3D"yiv8970500305ss-required-asterisk" style=3D"color:#c43b1d;">
*</span>
</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"yiv8970500305ss-q-text" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Conciente, l=C3=BAcida y orientada, PA y pulso: normales, SatO2: 96% Afebril,C:RR2TSS. P:MP disminuido,SRA. ABD:BDI. EXT: disminuci=C3=B3n de fuerzas en EEII.Con cervicalgia derecha moderada.</div>
</div>
</div>
</div>
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 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item yiv8970500305ss-item-required yiv8970500305ss-text" style=3D"margin:12px 0;">
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<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_1690694733" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Diagn=C3=B3stico<label style=3D"">
</label>
<span class=3D"yiv8970500305ss-required-asterisk" style=3D"color:#c43b1d;">
*</span>
</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"yiv8970500305ss-q-text" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
C=C3=A1ncer de Mama avanzado, con met=C3=A1stasis =C3=B3seas. TEP masivo recuperado. Cervicalgia.</div>
</div>
</div>
</div>
<br>
 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item yiv8970500305ss-item-required yiv8970500305ss-paragraph-text" style=3D"margin:12px 0;">
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<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_1255665248" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Plan de Tratamiento e Indicaciones<label style=3D"">
</label>
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*</span>
</div>
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</div>
</label>
<div class=3D"yiv8970500305ss-q-text" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Manejo paliativo del dolor, y manejo del compromiso respiratorio secundario al TEP masivo recuperado. Manejo postural, manejo kin=C3==A9sico motor y respiratorio. Uso de triflow. Oxigenoterapia: 2lts x minuto. Prevenci=C3=B3n de Escaras.</div>
</div>
</div>
</div>
<br>
 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item  yiv8970500305ss-paragraph-text" style==3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_1648939075" style=3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Medicamentos Indicados</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"yiv8970500305ss-q-text" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Agrego CELEBRA 200mg: 1 cada 12horas x 5 dias. Se mantiene el resto de las indicaciones.</div>
</div>
</div>
</div>
<br>
 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item  yiv8970500305ss-date" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_2063615873" style=3D"">
<div class=3D"yiv8970500305ss-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"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"yiv8970500305ss-q-date" style=3D"">
<div class=3D"yiv8970500305ss-datetime-box yiv8970500305goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;position:relative;display:inline-block;">
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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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D=C3=ADa</option>
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1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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A=C3=B1o</option>
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1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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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>
 <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>
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</div>
<br>
 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item  yiv8970500305ss-text" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_74766472" style==3D"">
<div class=3D"yiv8970500305ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" style==3D"display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"yiv8970500305ss-q-text" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
Se indican controles con Enfermera y Kinesiologo, para manejo de secuelas del TEP (atelectasias, hipoventilacion, etc.), y para mejorar la disminuci=C3=B3n de fuerzas en ambas EEII.</div>
</div>
</div>
</div>
<br>
 <div class=3D"yiv8970500305ss-form-question yiv8970500305errorbox-good" style=3D"">
<div class=3D"yiv8970500305ss-item  yiv8970500305ss-checkbox" style=3D"margin:12px 0;">
<div class=3D"yiv8970500305ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"yiv8970500305ss-q-item-label" for=3D"entry_1219705969" style=3D"">
<div class=3D"yiv8970500305ss-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"yiv8970500305ss-q-help yiv8970500305ss-secondary-text" 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>
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<input type=3D"checkbox" name=3D"entry.503039759" disabled=3D"" checked=3D"" value=3D"ENFERMERA" id=3D"yiv8970500305group_503039759_1" class=3D"yiv8970500305ss-q-checkbox" style=3D"">
</span>
<span class=3D"yiv8970500305ss-choice-label" style=3D"">
ENFERMERA</span>
</label>
</li>
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<label>
<span class=3D"yiv8970500305ss-choice-item-control yiv8970500305goog-inline-block" style=3D"position:relative;display:inline-block;">
<input type=3D"checkbox" name=3D"entry.503039759" disabled=3D"" value=3D"TENS" id=3D"yiv8970500305group_503039759_2" class=3D"yiv8970500305ss-q-checkbox" style==3D"">
</span>
<span class=3D"yiv8970500305ss-choice-label" style=3D"">
TENS</span>
</label>
</li>
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<label>
<span class=3D"yiv8970500305ss-choice-item-control yiv8970500305goog-inline-block" style=3D"position:relative;display:inline-block;">
<input type=3D"checkbox" name=3D"entry.503039759" disabled=3D"" value=3D"NUTRICIONISTA" id=3D"yiv8970500305group_503039759_3" class=3D"yiv8970500305ss-q-checkbox" style=3D"">
</span>
<span class=3D"yiv8970500305ss-choice-label" style=3D"">
NUTRICIONISTA</span>
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