X-AntiAbuse: Primary Hostname - ns1.hostnow.clX-AntiAbuse: Original Domain - telemed-chile.clX-AntiAbuse: Originator/Caller UID/GID - [47 12] / [47 12]X-AntiAbuse: Sender Address Domain - gmail.comX-Get-Message-Sender-Via: ns1.hostnow.cl: redirect/forwarder owner informeges@telemed-chile.cl ->
 informeges@inhedo.comX-Authenticated-Sender: ns1.hostnow.cl: informeges@telemed-chile.clX-Source: X-Source-Args: X-Source-Dir: X-Spam-Status: Yes, score=5.6X-Spam-Score: 56X-Spam-Bar: +++++X-Spam-Report: Spam detection software, running on the system "host213.hostmonster.com", has identified this incoming email as possible spam.  The original message has been attached to this so you can view it or label similar future email.  If you have any questions, see root\@localhost for details.  Content preview:  Enviado desde mi HUAWEI Mate 20 lite -------- Mensaje original    -------- Asunto: Registro de Atención Domiciliaria Oncovida De: Formularios    de Google Para: Gracias por rellenar Registro de Atención  Content analysis details:   (5.6 points, 5.0 required)   pts rule name              description ---- ---------------------- --------------------------------------------------  0.0 URIBL_BLOCKED          ADMINISTRATOR NOTICE: The query to URIBL was blocked.                             See                             http://wiki.apache.org/spamassassin/DnsBlocklists#dnsbl-block                              for more information.                             [URIs: docs.google.com]  1.0 SPF_SOFTFAIL           SPF: sender does not match SPF record (softfail)  0.5 FREEMAIL_FROM          Sender email is commonly abused enduser mail provider                             (sandramaulenangel[at]gmail.com)  1.1 MIME_HTML_ONLY         BODY: Message only has text/html MIME parts  2.4 HTML_OBFUSCATE_20_30   BODY: Message is 20% to 30% HTML obfuscation  0.0 HTML_MESSAGE           BODY: HTML included in message -0.1 DKIM_VALID             Message has at least one valid DKIM or DK signature -0.1 DKIM_VALID_AU          Message has a valid DKIM or DK signature from author's                             domain  0.1 DKIM_SIGNED            Message has a DKIM or DK signature, not necessarily valid  0.6 HTML_MIME_NO_HTML_TAG  HTML-only message, but there is no HTML tagX-Spam-Flag: NO<br>
<br>
Enviado desde mi HUAWEI Mate 20 lite<div style="line-height:1.5">
<br>
<br>
-------- Mensaje original --------<br>
Asunto: Registro de Atención Domiciliaria Oncovida<br>
De: Formularios de Google <forms-receipts-noreply@google.com>
<br>
Para: SANDRAMAULENANGEL@GMAIL.COM<br>
CC: <br>
<br>
<blockquote style="margin:0 0 0 0.8ex;border-left:1px #ccc solid;padding-left:1ex">
<blockquote class="quote" style="margin:0 0 0 .8ex;border-left:1px #ccc solid;padding-left:1ex">
<div style="font-family:&#39;roboto&#39; , &#39;helvetica&#39; , &#39;arial&#39; , sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border="0" cellpadding="0" cellspacing="0" style="background-color:rgb( 38 , 4 , 154 )" width="100%">
<tbody>
<tr>
<td style="padding-left:24px">
<img alt="Formularios de Google" height="26px" style="display:inline-block;margin:0;vertical-align:middle" width="143px" src="https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png" />
</td>
</tr>
</tbody>
</table>
<div style="padding:24px;background-color:rgb( 229 , 218 , 254 )">
<div align="center" style="background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align="center" cellpadding="0" cellspacing="0" style="background-color:#fff" width="100%">
<tbody>
<tr>
<td>
</td>
</tr>
<tr>
<td>
<div style="font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por rellenar <a href="https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp&#61;mail_form_link">
Registro de Atención Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr>
</tr>
<tr>
<td>
<div style="font-size:13px;line-height:18px;color:#424242">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div>
<div>
<h1 dir="ltr" style="margin:0.67em 0">
Registro de Atención Domiciliaria Oncovida</h1>

<div style="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 continuación indique su correo electrónico.</div>

</div>

<div>
<form action="" method="GET">
<br />

<div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Dirección de correo electrónico
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
SANDRAMAULENANGEL&#64;GMAIL.COM</div>



</div>
</div>
</div>

<div>

<div dir="auto" style="margin:12px 0;max-width:100%">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
</h2>

<div style="text-align:right">
<img src="https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style="width:78px;outline:none" alt="Imagen sin leyenda" />
</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="margin:2em 0;padding:0.4em;background-color:#eee">
Identificación del Prestador</h2>

<div dir="auto" style="white-space:pre-wrap;word-wrap:break-word">
Aquí debe ingresar sus datos personales</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Primer Nombre y Apellido Paterno
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
SANDRA MAULEN </div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
RUT
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
16621429-7</div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Tipo
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
Si asisten más de 1 prestador simultáneamente, cada uno debe hacer un registro independiente</div>


<select name="entry.133691676" disabled="disabled">
<option value="">
</option>
<option value="MEDICO" disabled="disabled">
MEDICO</option>
<option value="ENFERMERA/O" disabled="disabled" selected="selected">
ENFERMERA/O</option>
<option value="TENS" disabled="disabled">
TENS</option>
<option value="KINESIOLOGA/O" disabled="disabled">
KINESIOLOGA/O</option>
<option value="PSICOLOGO" disabled="disabled">
PSICOLOGO</option>
<option value="NUTRICIONISTA" disabled="disabled">
NUTRICIONISTA</option>
</select>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0;max-width:100%">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
</h2>

<div style="text-align:right">
<img src="https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style="width:78px;outline:none" alt="Imagen sin leyenda" />
</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="margin:2em 0;padding:0.4em;background-color:#eee">
Identificación del Paciente</h2>

<div dir="auto" style="white-space:pre-wrap;word-wrap:break-word">
En esta sección debe ingresar los datos del paciente visitado</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="background-color:#eee;padding:0.4em;margin:2em 0">
Datos Personales del Paciente</h2>

<div style="margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word">
</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Ingrese el Rut del Paciente
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
5073324-6</div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
EMMA PINO </div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Previsión
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<select name="entry.545002227" disabled="disabled">
<option value="">
</option>
<option value="BANMEDICA" disabled="disabled" selected="selected">
BANMEDICA</option>
<option value="CAPREDENA" disabled="disabled">
CAPREDENA</option>
<option value="COLMENA" disabled="disabled">
COLMENA</option>
<option value="CONSALUD" disabled="disabled">
CONSALUD</option>
<option value="CRUZ BLANCA" disabled="disabled">
CRUZ BLANCA</option>
<option value="DIPRECA" disabled="disabled">
DIPRECA</option>
<option value="FONASA" disabled="disabled">
FONASA</option>
<option value="FUNDACION" disabled="disabled">
FUNDACION</option>
<option value="ISAPRES DEL COBRE" disabled="disabled">
ISAPRES DEL COBRE</option>
<option value="NUEVA MASVIDA" disabled="disabled">
NUEVA MASVIDA</option>
<option value="VIDATRES" disabled="disabled">
VIDATRES</option>
<option value="PARTICULAR" disabled="disabled">
PARTICULAR</option>
</select>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Ciudad
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
VALPARAISO </div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Comuna
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
VALPARAISO </div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0;max-width:100%">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
</h2>

<div style="text-align:right">
<img src="https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style="width:78px;outline:none" alt="Imagen sin leyenda" />
</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="margin:2em 0;padding:0.4em;background-color:#eee">
Registro de la Atención Domiciliaria</h2>

<div dir="auto" style="white-space:pre-wrap;word-wrap:break-word">
En esta sección debe ingresar los datos de la atención domiciliaria</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Tipo de Atención
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>



<ul style="list-style:none;padding:0;margin:0.5em 0 0">
<li style="margin:0;line-height:1.3em;padding-bottom:0.5em">

<label>
<span style="display:inline-block">
<input type="radio" name="entry.1222378237" disabled="disabled" checked="checked" value="Domicilio" />
</span>

Domicilio
</label>
</li>
<li style="margin:0;line-height:1.3em;padding-bottom:0.5em">

<label>
<span style="display:inline-block">
<input type="radio" name="entry.1222378237" disabled="disabled" value="Ambulatorio" />
</span>

Ambulatorio
</label>
</li>
</ul>


</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Fecha de la Atención
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div>
<div style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name="entry.1705849412_day" disabled="disabled">
<option value="">
Día</option>
<option value="1">
1</option>
<option value="2">
2</option>
<option value="3">
3</option>
<option value="4" selected="selected">
4</option>
<option value="5">
5</option>
<option value="6">
6</option>
<option value="7">
7</option>
<option value="8">
8</option>
<option value="9">
9</option>
<option value="10">
10</option>
<option value="11">
11</option>
<option value="12">
12</option>
<option value="13">
13</option>
<option value="14">
14</option>
<option value="15">
15</option>
<option value="16">
16</option>
<option value="17">
17</option>
<option value="18">
18</option>
<option value="19">
19</option>
<option value="20">
20</option>
<option value="21">
21</option>
<option value="22">
22</option>
<option value="23">
23</option>
<option value="24">
24</option>
<option value="25">
25</option>
<option value="26">
26</option>
<option value="27">
27</option>
<option value="28">
28</option>
<option value="29">
29</option>
<option value="30">
30</option>
<option value="31">
31</option>
</select>
   <select name="entry.1705849412_month" disabled="disabled">
<option value="">
Mes</option>
<option value="1">
enero</option>
<option value="2">
febrero</option>
<option value="3">
marzo</option>
<option value="4" selected="selected">
abril</option>
<option value="5">
mayo</option>
<option value="6">
junio</option>
<option value="7">
julio</option>
<option value="8">
agosto</option>
<option value="9">
septiembre</option>
<option value="10">
octubre</option>
<option value="11">
noviembre</option>
<option value="12">
diciembre</option>
</select>
 
<select name="entry.1705849412_year" disabled="disabled">
<option value="">
Año</option>
<option value="1896">
1896</option>
<option value="1897">
1897</option>
<option value="1898">
1898</option>
<option value="1899">
1899</option>
<option value="1900">
1900</option>
<option value="1901">
1901</option>
<option value="1902">
1902</option>
<option value="1903">
1903</option>
<option value="1904">
1904</option>
<option value="1905">
1905</option>
<option value="1906">
1906</option>
<option value="1907">
1907</option>
<option value="1908">
1908</option>
<option value="1909">
1909</option>
<option value="1910">
1910</option>
<option value="1911">
1911</option>
<option value="1912">
1912</option>
<option value="1913">
1913</option>
<option value="1914">
1914</option>
<option value="1915">
1915</option>
<option value="1916">
1916</option>
<option value="1917">
1917</option>
<option value="1918">
1918</option>
<option value="1919">
1919</option>
<option value="1920">
1920</option>
<option value="1921">
1921</option>
<option value="1922">
1922</option>
<option value="1923">
1923</option>
<option value="1924">
1924</option>
<option value="1925">
1925</option>
<option value="1926">
1926</option>
<option value="1927">
1927</option>
<option value="1928">
1928</option>
<option value="1929">
1929</option>
<option value="1930">
1930</option>
<option value="1931">
1931</option>
<option value="1932">
1932</option>
<option value="1933">
1933</option>
<option value="1934">
1934</option>
<option value="1935">
1935</option>
<option value="1936">
1936</option>
<option value="1937">
1937</option>
<option value="1938">
1938</option>
<option value="1939">
1939</option>
<option value="1940">
1940</option>
<option value="1941">
1941</option>
<option value="1942">
1942</option>
<option value="1943">
1943</option>
<option value="1944">
1944</option>
<option value="1945">
1945</option>
<option value="1946">
1946</option>
<option value="1947">
1947</option>
<option value="1948">
1948</option>
<option value="1949">
1949</option>
<option value="1950">
1950</option>
<option value="1951">
1951</option>
<option value="1952">
1952</option>
<option value="1953">
1953</option>
<option value="1954">
1954</option>
<option value="1955">
1955</option>
<option value="1956">
1956</option>
<option value="1957">
1957</option>
<option value="1958">
1958</option>
<option value="1959">
1959</option>
<option value="1960">
1960</option>
<option value="1961">
1961</option>
<option value="1962">
1962</option>
<option value="1963">
1963</option>
<option value="1964">
1964</option>
<option value="1965">
1965</option>
<option value="1966">
1966</option>
<option value="1967">
1967</option>
<option value="1968">
1968</option>
<option value="1969">
1969</option>
<option value="1970">
1970</option>
<option value="1971">
1971</option>
<option value="1972">
1972</option>
<option value="1973">
1973</option>
<option value="1974">
1974</option>
<option value="1975">
1975</option>
<option value="1976">
1976</option>
<option value="1977">
1977</option>
<option value="1978">
1978</option>
<option value="1979">
1979</option>
<option value="1980">
1980</option>
<option value="1981">
1981</option>
<option value="1982">
1982</option>
<option value="1983">
1983</option>
<option value="1984">
1984</option>
<option value="1985">
1985</option>
<option value="1986">
1986</option>
<option value="1987">
1987</option>
<option value="1988">
1988</option>
<option value="1989">
1989</option>
<option value="1990">
1990</option>
<option value="1991">
1991</option>
<option value="1992">
1992</option>
<option value="1993">
1993</option>
<option value="1994">
1994</option>
<option value="1995">
1995</option>
<option value="1996">
1996</option>
<option value="1997">
1997</option>
<option value="1998">
1998</option>
<option value="1999">
1999</option>
<option value="2000">
2000</option>
<option value="2001">
2001</option>
<option value="2002">
2002</option>
<option value="2003">
2003</option>
<option value="2004">
2004</option>
<option value="2005">
2005</option>
<option value="2006">
2006</option>
<option value="2007">
2007</option>
<option value="2008">
2008</option>
<option value="2009">
2009</option>
<option value="2010">
2010</option>
<option value="2011">
2011</option>
<option value="2012">
2012</option>
<option value="2013">
2013</option>
<option value="2014">
2014</option>
<option value="2015">
2015</option>
<option value="2016">
2016</option>
<option value="2017">
2017</option>
<option value="2018">
2018</option>
<option value="2019" selected="selected">
2019</option>
<option value="2020">
2020</option>
<option value="2021">
2021</option>
<option value="2022">
2022</option>
<option value="2023">
2023</option>
<option value="2024">
2024</option>
<option value="2025">
2025</option>
<option value="2026">
2026</option>
<option value="2027">
2027</option>
<option value="2028">
2028</option>
<option value="2029">
2029</option>
<option value="2030">
2030</option>
<option value="2031">
2031</option>
<option value="2032">
2032</option>
<option value="2033">
2033</option>
<option value="2034">
2034</option>
<option value="2035">
2035</option>
<option value="2036">
2036</option>
<option value="2037">
2037</option>
<option value="2038">
2038</option>
<option value="2039">
2039</option>
<option value="2040">
2040</option>
<option value="2041">
2041</option>
<option value="2042">
2042</option>
<option value="2043">
2043</option>
<option value="2044">
2044</option>
<option value="2045">
2045</option>
<option value="2046">
2046</option>
<option value="2047">
2047</option>
<option value="2048">
2048</option>
<option value="2049">
2049</option>
<option value="2050">
2050</option>
<option value="2051">
2051</option>
<option value="2052">
2052</option>
<option value="2053">
2053</option>
<option value="2054">
2054</option>
<option value="2055">
2055</option>
<option value="2056">
2056</option>
<option value="2057">
2057</option>
<option value="2058">
2058</option>
<option value="2059">
2059</option>
<option value="2060">
2060</option>
<option value="2061">
2061</option>
<option value="2062">
2062</option>
<option value="2063">
2063</option>
<option value="2064">
2064</option>
<option value="2065">
2065</option>
<option value="2066">
2066</option>
<option value="2067">
2067</option>
<option value="2068">
2068</option>
<option value="2069">
2069</option>
</select>

</div>

</div>
</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0;font:inherit">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Hora de la Atención
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div>
<div dir="ltr" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
<select name="entry.206244955_hour" disabled="disabled">
<option value="">
h</option>
<option value="00">
00</option>
<option value="01">
01</option>
<option value="02">
02</option>
<option value="03">
03</option>
<option value="04">
04</option>
<option value="05">
05</option>
<option value="06">
06</option>
<option value="07">
07</option>
<option value="08">
08</option>
<option value="09" selected="selected">
09</option>
<option value="10">
10</option>
<option value="11">
11</option>
<option value="12">
12</option>
<option value="13">
13</option>
<option value="14">
14</option>
<option value="15">
15</option>
<option value="16">
16</option>
<option value="17">
17</option>
<option value="18">
18</option>
<option value="19">
19</option>
<option value="20">
20</option>
<option value="21">
21</option>
<option value="22">
22</option>
<option value="23">
23</option>
</select>

:
<select name="entry.206244955_minute" disabled="disabled">
<option value="">
min</option>
<option value="00">
00</option>
<option value="01">
01</option>
<option value="02">
02</option>
<option value="03">
03</option>
<option value="04">
04</option>
<option value="05">
05</option>
<option value="06">
06</option>
<option value="07">
07</option>
<option value="08">
08</option>
<option value="09">
09</option>
<option value="10">
10</option>
<option value="11">
11</option>
<option value="12">
12</option>
<option value="13">
13</option>
<option value="14">
14</option>
<option value="15">
15</option>
<option value="16">
16</option>
<option value="17">
17</option>
<option value="18">
18</option>
<option value="19">
19</option>
<option value="20">
20</option>
<option value="21">
21</option>
<option value="22">
22</option>
<option value="23">
23</option>
<option value="24">
24</option>
<option value="25">
25</option>
<option value="26">
26</option>
<option value="27">
27</option>
<option value="28">
28</option>
<option value="29">
29</option>
<option value="30">
30</option>
<option value="31">
31</option>
<option value="32">
32</option>
<option value="33">
33</option>
<option value="34">
34</option>
<option value="35">
35</option>
<option value="36">
36</option>
<option value="37">
37</option>
<option value="38">
38</option>
<option value="39">
39</option>
<option value="40">
40</option>
<option value="41">
41</option>
<option value="42">
42</option>
<option value="43">
43</option>
<option value="44">
44</option>
<option value="45" selected="selected">
45</option>
<option value="46">
46</option>
<option value="47">
47</option>
<option value="48">
48</option>
<option value="49">
49</option>
<option value="50">
50</option>
<option value="51">
51</option>
<option value="52">
52</option>
<option value="53">
53</option>
<option value="54">
54</option>
<option value="55">
55</option>
<option value="56">
56</option>
<option value="57">
57</option>
<option value="58">
58</option>
<option value="59">
59</option>
</select>



<div style="height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Performance Status ECOG del Paciente
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<select name="entry.1747608258" disabled="disabled">
<option value="">
</option>
<option value="0" disabled="disabled">
0</option>
<option value="1" disabled="disabled">
1</option>
<option value="2" disabled="disabled">
2</option>
<option value="3" disabled="disabled" selected="selected">
3</option>
<option value="4" disabled="disabled">
4</option>
</select>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Escala Dolor EVA Actual
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>



<table border="0" cellpadding="5" cellspacing="0">
<tr>
<td style="text-align:center">
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
0</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
1</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
2</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
3</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
4</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
5</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
6</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
7</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
8</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
9</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
10</label>
</td>
<td style="text-align:center">
</td>
</tr>
<tr>
<td style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em;padding-left:0">
<div>
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="0" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="1" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" checked="checked" value="2" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="3" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="4" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="5" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="6" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="7" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="8" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="9" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="10" />
</div>
</td>
<td style="text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em;padding-right:0">
</td>
</tr>
</table>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Escala Dolor EVA Máximo
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>



<table border="0" cellpadding="5" cellspacing="0">
<tr>
<td style="text-align:center">
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
0</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
1</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
2</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
3</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
4</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
5</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
6</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
7</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
8</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
9</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
10</label>
</td>
<td style="text-align:center">
</td>
</tr>
<tr>
<td style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em;padding-left:0">
<div>
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="0" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="1" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="2" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="3" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="4" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="5" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="6" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="7" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" checked="checked" value="8" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="9" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="10" />
</div>
</td>
<td style="text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em;padding-right:0">
</td>
</tr>
</table>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Escala Dolor EVA Mínimo
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>



<table border="0" cellpadding="5" cellspacing="0">
<tr>
<td style="text-align:center">
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
0</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
1</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
2</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
3</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
4</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
5</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
6</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
7</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
8</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
9</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
10</label>
</td>
<td style="text-align:center">
</td>
</tr>
<tr>
<td style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em;padding-left:0">
<div>
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" checked="checked" value="0" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="1" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="2" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="3" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="4" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="5" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="6" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="7" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="8" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="9" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.853118630" disabled="disabled" value="10" />
</div>
</td>
<td style="text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em;padding-right:0">
</td>
</tr>
</table>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Anamnesis/Evolución
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
PACIENTE EN REGULAR ESTADO GENERAL CON MINIMA DISNEA AL ESFUERZO 
CON REQUERIMIENTO DE OXIGENO MUY CANSADA PARA HABLAR PARA MOVERSE. PERFUSION DISTAL REGULAR.
ACTIVIDADES DE LA VIDA DIARIA NO REALIZADAS DE MANERA AUTONOMA CON REQUERIMIENTO DE AYUDA.
ALIMENTACION NO MUY BIEN TOLERADA, COMO EN POCAS CANTIDADES 
REPOSO Y SUEÑO NO MUY BIEN TOLERADO, MUY INQUIETA NO LOGRA CONCRETAR BIEN EL SUEÑO.</div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Examen Físico
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
PACIENTE A PESAR DE TODO CON HEMODINAMIA ESTABLE AFEBRIL NORMOCARDICA DE 67X NORMOTENSA DE 123/68 SATURACION OPTIMA DE 92% CON 1,5 LITRO DE OXIGENO POR BIGOTERA A PERMANENCIA.
PIEL SANA SIN LESIONES HIDRATADA
PERFUSION DISTAL REGULAR EXTREMIADES CON PULSOS DEBILES FRIAS, EDEMA TRES CRUCES EN EXTREMIDADES INFERIORES, PACIENTE EN OCASIONES RECHAZA TTO DE FUROSEMIDA, EDUCO EN LUBRICACION DE PIEL MASAJES ASCENDENTES ALZA TALON, EJERCICIOS.
DIURESIS NORMALES DIARIAS DEBITOS NORMALES 
DEPOSICIONES NORMALES CADA 2 DIAS.</div>



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</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Diagnóstico
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
CA PULMONAR </div>



</div>
</div>
</div>

<br />
 <div>

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<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Plan de Tratamiento e Indicaciones
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
- MANEJO DEL DOLOR
. SENTAR MAS SEMISENTADA NO MUY RECOSTADA
- USO ADECUADO DE DIURETICOS
- MANEJO EMOCIONAL CON PSICOLOGA 
- APOYO KINESICO Y NUTRICIONAL </div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Medicamentos Indicados
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
- MANEJO DEL DOLOR CON 1/2 TRANSTEC CAMBIO CADA 72 HORAS
- PARACETAMOL 1 GR CADA 8 HORAS EN SOS </div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Fecha aproximada del Próximo Control con usted
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div>
<div style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name="entry.2063615873_day" disabled="disabled">
<option value="">
Día</option>
<option value="1">
1</option>
<option value="2">
2</option>
<option value="3">
3</option>
<option value="4">
4</option>
<option value="5">
5</option>
<option value="6">
6</option>
<option value="7">
7</option>
<option value="8">
8</option>
<option value="9" selected="selected">
9</option>
<option value="10">
10</option>
<option value="11">
11</option>
<option value="12">
12</option>
<option value="13">
13</option>
<option value="14">
14</option>
<option value="15">
15</option>
<option value="16">
16</option>
<option value="17">
17</option>
<option value="18">
18</option>
<option value="19">
19</option>
<option value="20">
20</option>
<option value="21">
21</option>
<option value="22">
22</option>
<option value="23">
23</option>
<option value="24">
24</option>
<option value="25">
25</option>
<option value="26">
26</option>
<option value="27">
27</option>
<option value="28">
28</option>
<option value="29">
29</option>
<option value="30">
30</option>
<option value="31">
31</option>
</select>
   <select name="entry.2063615873_month" disabled="disabled">
<option value="">
Mes</option>
<option value="1">
enero</option>
<option value="2">
febrero</option>
<option value="3">
marzo</option>
<option value="4" selected="selected">
abril</option>
<option value="5">
mayo</option>
<option value="6">
junio</option>
<option value="7">
julio</option>
<option value="8">
agosto</option>
<option value="9">
septiembre</option>
<option value="10">
octubre</option>
<option value="11">
noviembre</option>
<option value="12">
diciembre</option>
</select>
 
<select name="entry.2063615873_year" disabled="disabled">
<option value="">
Año</option>
<option value="1896">
1896</option>
<option value="1897">
1897</option>
<option value="1898">
1898</option>
<option value="1899">
1899</option>
<option value="1900">
1900</option>
<option value="1901">
1901</option>
<option value="1902">
1902</option>
<option value="1903">
1903</option>
<option value="1904">
1904</option>
<option value="1905">
1905</option>
<option value="1906">
1906</option>
<option value="1907">
1907</option>
<option value="1908">
1908</option>
<option value="1909">
1909</option>
<option value="1910">
1910</option>
<option value="1911">
1911</option>
<option value="1912">
1912</option>
<option value="1913">
1913</option>
<option value="1914">
1914</option>
<option value="1915">
1915</option>
<option value="1916">
1916</option>
<option value="1917">
1917</option>
<option value="1918">
1918</option>
<option value="1919">
1919</option>
<option value="1920">
1920</option>
<option value="1921">
1921</option>
<option value="1922">
1922</option>
<option value="1923">
1923</option>
<option value="1924">
1924</option>
<option value="1925">
1925</option>
<option value="1926">
1926</option>
<option value="1927">
1927</option>
<option value="1928">
1928</option>
<option value="1929">
1929</option>
<option value="1930">
1930</option>
<option value="1931">
1931</option>
<option value="1932">
1932</option>
<option value="1933">
1933</option>
<option value="1934">
1934</option>
<option value="1935">
1935</option>
<option value="1936">
1936</option>
<option value="1937">
1937</option>
<option value="1938">
1938</option>
<option value="1939">
1939</option>
<option value="1940">
1940</option>
<option value="1941">
1941</option>
<option value="1942">
1942</option>
<option value="1943">
1943</option>
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1944</option>
<option value="1945">
1945</option>
<option value="1946">
1946</option>
<option value="1947">
1947</option>
<option value="1948">
1948</option>
<option value="1949">
1949</option>
<option value="1950">
1950</option>
<option value="1951">
1951</option>
<option value="1952">
1952</option>
<option value="1953">
1953</option>
<option value="1954">
1954</option>
<option value="1955">
1955</option>
<option value="1956">
1956</option>
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1957</option>
<option value="1958">
1958</option>
<option value="1959">
1959</option>
<option value="1960">
1960</option>
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1961</option>
<option value="1962">
1962</option>
<option value="1963">
1963</option>
<option value="1964">
1964</option>
<option value="1965">
1965</option>
<option value="1966">
1966</option>
<option value="1967">
1967</option>
<option value="1968">
1968</option>
<option value="1969">
1969</option>
<option value="1970">
1970</option>
<option value="1971">
1971</option>
<option value="1972">
1972</option>
<option value="1973">
1973</option>
<option value="1974">
1974</option>
<option value="1975">
1975</option>
<option value="1976">
1976</option>
<option value="1977">
1977</option>
<option value="1978">
1978</option>
<option value="1979">
1979</option>
<option value="1980">
1980</option>
<option value="1981">
1981</option>
<option value="1982">
1982</option>
<option value="1983">
1983</option>
<option value="1984">
1984</option>
<option value="1985">
1985</option>
<option value="1986">
1986</option>
<option value="1987">
1987</option>
<option value="1988">
1988</option>
<option value="1989">
1989</option>
<option value="1990">
1990</option>
<option value="1991">
1991</option>
<option value="1992">
1992</option>
<option value="1993">
1993</option>
<option value="1994">
1994</option>
<option value="1995">
1995</option>
<option value="1996">
1996</option>
<option value="1997">
1997</option>
<option value="1998">
1998</option>
<option value="1999">
1999</option>
<option value="2000">
2000</option>
<option value="2001">
2001</option>
<option value="2002">
2002</option>
<option value="2003">
2003</option>
<option value="2004">
2004</option>
<option value="2005">
2005</option>
<option value="2006">
2006</option>
<option value="2007">
2007</option>
<option value="2008">
2008</option>
<option value="2009">
2009</option>
<option value="2010">
2010</option>
<option value="2011">
2011</option>
<option value="2012">
2012</option>
<option value="2013">
2013</option>
<option value="2014">
2014</option>
<option value="2015">
2015</option>
<option value="2016">
2016</option>
<option value="2017">
2017</option>
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2018</option>
<option value="2019" selected="selected">
2019</option>
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2020</option>
<option value="2021">
2021</option>
<option value="2022">
2022</option>
<option value="2023">
2023</option>
<option value="2024">
2024</option>
<option value="2025">
2025</option>
<option value="2026">
2026</option>
<option value="2027">
2027</option>
<option value="2028">
2028</option>
<option value="2029">
2029</option>
<option value="2030">
2030</option>
<option value="2031">
2031</option>
<option value="2032">
2032</option>
<option value="2033">
2033</option>
<option value="2034">
2034</option>
<option value="2035">
2035</option>
<option value="2036">
2036</option>
<option value="2037">
2037</option>
<option value="2038">
2038</option>
<option value="2039">
2039</option>
<option value="2040">
2040</option>
<option value="2041">
2041</option>
<option value="2042">
2042</option>
<option value="2043">
2043</option>
<option value="2044">
2044</option>
<option value="2045">
2045</option>
<option value="2046">
2046</option>
<option value="2047">
2047</option>
<option value="2048">
2048</option>
<option value="2049">
2049</option>
<option value="2050">
2050</option>
<option value="2051">
2051</option>
<option value="2052">
2052</option>
<option value="2053">
2053</option>
<option value="2054">
2054</option>
<option value="2055">
2055</option>
<option value="2056">
2056</option>
<option value="2057">
2057</option>
<option value="2058">
2058</option>
<option value="2059">
2059</option>
<option value="2060">
2060</option>
<option value="2061">
2061</option>
<option value="2062">
2062</option>
<option value="2063">
2063</option>
<option value="2064">
2064</option>
<option value="2065">
2065</option>
<option value="2066">
2066</option>
<option value="2067">
2067</option>
<option value="2068">
2068</option>
<option value="2069">
2069</option>
</select>

</div>

</div>
</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Tratamiento Realizado (si corresponde)
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>


<div dir="auto" style="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>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
</label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Derivación a otro Prestador Domiciliario
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
Sólo llene esta sección si es médico y solicita la visita de otro prestador del equipo</div>



<ul style="list-style:none;padding:0;margin:0.5em 0 0">
<li style="margin:0;line-height:1.3em;padding-bottom:0.5em">

<label>
<span style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="disabled" value="ENFERMERA" />
</span>

ENFERMERA
</label>
</li>
<li style="margin:0;line-height:1.3em;padding-bottom:0.5em">

<label>
<span style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="disabled" value="TENS" />
</span>

TENS
</label>
</li>
<li style="margin:0;line-height:1.3em;padding-bottom:0.5em">

<label>
<span style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="disabled" value="NUTRICIONISTA" />
</span>

NUTRICIONISTA
</label>
</li>
<li style="margin:0;line-height:1.3em;padding-bottom:0.5em">

<label>
<span style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="disabled" value="KINESIOLOGO" />
</span>

KINESIOLOGO
</label>
</li>
<li style="margin:0;line-height:1.3em;padding-bottom:0.5em">

<label>
<span style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="disabled" value="PSICOLOGO" />
</span>

PSICOLOGO
</label>
</li>
</ul>


</div>
</div>
</div>

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<h2 style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
</h2>

<div style="text-align:right">
<img src="https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style="width:78px;outline:none" alt="Imagen sin leyenda" />
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<table align="center" cellpadding="0" cellspacing="0" style="max-width:672px;min-width:154px" width="100%">
<tbody>
<tr>
<td>
</td>
</tr>
<tr>
<td>
<a href="https://docs.google.com/forms?usp&#61;mail_form_link" style="color:#424242;font-size:13px">
Crea tu propio formulario de Google</a>
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</blockquote>
</div>
b3RlPjwvZGl2Pg==