<div dir=3D"ltr">
<br>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class==3D"gmail_attr">
---------- Forwarded message ---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Formularios de Google</strong>
 <span dir=3D"ltr">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: dom., 7 abr. 2019 a las 14:33<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:elizabethcorreadiaz@gmail.com">
elizabethcorreadiaz@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Formularios de Google" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por rellenar <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target=3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_1749352385756662461ss-form-container">
<div class=3D"m_1749352385756662461ss-form-heading">
<h1 class=3D"m_1749352385756662461ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_1749352385756662461ss-form-desc m_1749352385756662461ss-no-ignore-whitespace" style=3D"font:inherit;width:99%;margin:0 0 1em;white-space:pre-wrap;word-wrap:break-word">
Este es el sistema de registro de atenciones domiciliarias de Oncovida.   Debe ser llenado por el prestador individual, y debe realizarse un registro por cada visita domiciliaria.   Si usted no es prestador de Oncovida por favor no llene este formulario.   A continuaci=C3=B3n indique su correo electr=C3=B3nico.</div>
</div>
<div class=3D"m_1749352385756662461ss-form">
<form method=3D"GET" id=3D"m_1749352385756662461ss-form" target=3D"_blank">
<br>
<div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-item-required m_1749352385756662461ss-text" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461emailAddress">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Direcci=C3==B3n de correo electr=C3=B3nico<label for=3D"m_1749352385756662461emailAddress">
</label>
<span class=3D"m_1749352385756662461ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_1749352385756662461ss-q-text m_1749352385756662461ss-printable-text-line" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
<a href=3D"mailto:elizabethcorreadiaz@gmail.com" target=3D"_blank">
elizabethcorreadiaz@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_1749352385756662461ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1749352385756662461ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_1749352385756662461ss-page-description m_1749352385756662461ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
Aqu=C3=AD debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-item-required m_1749352385756662461ss-text" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_579114469">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_1749352385756662461itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1749352385756662461ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1749352385756662461ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
ELIZABETH CORREA</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-item-required m_1749352385756662461ss-text" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_1276273985">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_1749352385756662461itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1749352385756662461ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_1749352385756662461ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
16203285-2</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-item-required m_1749352385756662461ss-select" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_133691676">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_1749352385756662461itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1749352385756662461ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
Si asisten m=C3=A1s de 1 prestador simult=C3=A1neamente, cada uno debe hacer un registro independiente</div>
</label>
<select name=3D"entry.133691676" disabled id=3D"m_1749352385756662461entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled selected>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_1749352385756662461ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1749352385756662461ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_1749352385756662461ss-page-description m_1749352385756662461ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1749352385756662461ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_1749352385756662461ss-section-description m_1749352385756662461ss-no-ignore-whitespace" style=3D"margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-item-required m_1749352385756662461ss-text" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_823811303">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_1749352385756662461itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1749352385756662461ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_1749352385756662461ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
3437560-7</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-item-required m_1749352385756662461ss-text" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_1959365839">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente<label for=3D"m_1749352385756662461itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1749352385756662461ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1749352385756662461ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
MARIA ARANEDA</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-item-required m_1749352385756662461ss-select" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_545002227">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_1749352385756662461itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1749352385756662461ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.545002227" disabled id=3D"m_1749352385756662461entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled selected>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled>
COLMENA</option>
 <option value=3D"CONSALUD" disabled>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled>
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled>
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-item-required m_1749352385756662461ss-text" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_1900161356">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_1749352385756662461itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1749352385756662461ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1749352385756662461ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
VI=C3=91A DEL MAR</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-item-required m_1749352385756662461ss-text" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_1298871758">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_1749352385756662461itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1749352385756662461ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1749352385756662461ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
VI=C3=91A DEL MAR</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_1749352385756662461ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1749352385756662461ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_1749352385756662461ss-page-description m_1749352385756662461ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos de la atenci==C3=B3n domiciliaria</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-item-required m_1749352385756662461ss-radio" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_2073233714">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_1749352385756662461itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1749352385756662461ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_1749352385756662461ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_1749352385756662461ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_1749352385756662461ss-choice-item-control m_1749352385756662461goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Domicilio" id=3D"m_1749352385756662461group_1222378237_1" class=3D"m_1749352385756662461ss-q-radio">
</span>
<span class=3D"m_1749352385756662461ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_1749352385756662461ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_1749352385756662461ss-choice-item-control m_1749352385756662461goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Ambulatorio" id=3D"m_1749352385756662461group_1222378237_2" class=3D"m_1749352385756662461ss-q-radio">
</span>
<span class=3D"m_1749352385756662461ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-item-required m_1749352385756662461ss-date" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_1705849412">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha de la Atenci=C3=B3n<label for=3D"m_1749352385756662461itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1749352385756662461ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1749352385756662461ss-q-date">
<div class=3D"m_1749352385756662461ss-datetime-box m_1749352385756662461goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name=3D"entry.1705849412_day" disabled class=3D"m_1749352385756662461ss-day-dropdown" id=3D"m_1749352385756662461entry.1705849412_day">
<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
</select>
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<option value=3D"">
Mes</option>
<option value=3D"1">
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>
 <option value=3D"12">
diciembre</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_1749352385756662461entry.1705849412_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
 <option value=3D"1918">
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>
 <option value==3D"1930">
1930</option>
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1931</option>
 <option value==3D"1932">
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>
 <option value==3D"1946">
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>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
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1959</option>
 <option value==3D"1960">
1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
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>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
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1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
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>
 <option value==3D"2016">
2016</option>
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2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
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2023</option>
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2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-item-required m_1749352385756662461ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_206244955">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Hora de la Atenci=C3=B3n<label for=3D"m_1749352385756662461itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1749352385756662461ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1749352385756662461ss-q-time">
<div class=3D"m_1749352385756662461ss-datetime-box m_1749352385756662461goog-inline-block" dir=3D"ltr" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
<select name=3D"entry.206244955_hour" disabled id=3D"m_1749352385756662461entry.206244955_hour">
<option value=3D"">
h</option>
<option value=3D"00">
00</option>
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01</option>
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02</option>
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03</option>
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04</option>
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05</option>
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06</option>
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07</option>
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08</option>
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09</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16" selected>
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value==3D"22">
22</option>
 <option value=3D"23">
23</option>
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17</option>
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18</option>
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28</option>
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39</option>
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42</option>
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59</option>
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</div>
</div>
</div>
</div>
</div>
</div>
<br>
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<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_1749352385756662461itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1749352385756662461ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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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>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_1716090865">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
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<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_1749352385756662461entry_1421689035">
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<tr>
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</td>
<td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
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<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1421689035_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
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<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
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<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
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<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
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<div class=3D"m_1749352385756662461aria-todo">
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</div>
</td>
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<div class=3D"m_1749352385756662461ss-scalerow-fieldcell">
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</div>
</td>
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</div>
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</div>
</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_1749352385756662461group_1421689035_10" class=3D"m_1749352385756662461ss-q-radio">
</div>
</td>
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<div class==3D"m_1749352385756662461ss-scalerow-fieldcell">
<input type=3D"radio" name==3D"entry.1421689035" disabled value=3D"10" id=3D"m_1749352385756662461group_1421689035_11" class=3D"m_1749352385756662461ss-q-radio">
</div>
</td>
<td class=3D"m_1749352385756662461ss-scalerow m_1749352385756662461ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_2064050596">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=A1ximo</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_1749352385756662461entry_1244707512">
<tbody>
<tr>
<td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_1749352385756662461ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_1749352385756662461ss-scalerow m_1749352385756662461ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_1749352385756662461aria-todo">
</div>
</td>
<td class=3D"m_1749352385756662461ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_1749352385756662461ss-scalerow-fieldcell">
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<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
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Escala Dolor EVA M=C3=ADnimo</div>
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<tr>
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</td>
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0</label>
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1</label>
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2</label>
</td>
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3</label>
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4</label>
</td>
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5</label>
</td>
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<label class=3D"m_1749352385756662461ss-scalenumber" for=3D"m_1749352385756662461group_853118630_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
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7</label>
</td>
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8</label>
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9</label>
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10</label>
</td>
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</td>
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<tr>
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</div>
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</td>
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PACIENTE ESTABLE, SIN CAMBIOS IMPORTANTES EN ESTADO GENERAL DESDE ULTIMA VISITAPROXIMA SEMANA SERA EVALUADA POR ONCOLOGO UROLOGO A FIN DE DETERMINAR POSIBILIDAD DE TRATAMIENTO=20REFIERE DOLOR MINIMO INTERMITENTE EN REGION PERIANAL, ASOCIADA A HEMORRAGIA VIA VAGINAL INTERMITENTE ESCASASE HA REDUCIDO CONSIDERABLEMENTE DOLOR ARTICULAR AUMENTANDO AUTOVALENCIA CON TERAPIA KINESICAS</div>
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HEMODINAMIA ESTABLACLOTE COOPERADORA SV NORMALESMARCHA CONSERVADAPIEL SANA HIDRATADA BIEN PERFUNDIDACARDIO NORMALPULMONAR NORMALABDOMEN: BLANDO DEPRESIBLE, INDOLORO, VIA DE ACCESO URINARIO INDEMNE, SENSIBILIDAD ESCASA EN HIPOGASTRIOZONA DE PERINE, NUEVAMENTE AUMENTO DE FLUJO VAGINAL TIPO MICOTICO APARENTE, SE EVIDENCIA LESION EN BORDE POSTERIOR SIN AUMENTO DE TAMA=C3=91ANPEXTREMIDADES SIN LESIONES</div>
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<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_1690694733">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_1749352385756662461itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1749352385756662461ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1749352385756662461ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
CA URETRA OPERADO</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-item-required m_1749352385756662461ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_1255665248">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_1749352385756662461itemView.getDomIdToLabel()">
</label>
<span class=3D"m_1749352385756662461ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1749352385756662461ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
SE MANTIENEN</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_1648939075">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1749352385756662461ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
SE MANTIENEN</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-date" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_2063615873">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1749352385756662461ss-q-date">
<div class=3D"m_1749352385756662461ss-datetime-box m_1749352385756662461goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
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<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
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febrero</option>
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marzo</option>
 <option value=3D"4" selected>
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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<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
 <option value==3D"2018">
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>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
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2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-text" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_74766472">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_1749352385756662461ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461ss-form-question m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_1749352385756662461ss-q-item-label" for=3D"m_1749352385756662461entry_1219705969">
<div class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_1749352385756662461ss-q-help m_1749352385756662461ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
</label>
<ul class=3D"m_1749352385756662461ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_1749352385756662461ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_1749352385756662461ss-choice-item-control m_1749352385756662461goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"ENFERMERA" id=3D"m_1749352385756662461group_503039759_1" class=3D"m_1749352385756662461ss-q-checkbox">
</span>
<span class=3D"m_1749352385756662461ss-choice-label">
ENFERMERA</span>
</label>
</li>
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<label>
<span class=3D"m_1749352385756662461ss-choice-item-control m_1749352385756662461goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_1749352385756662461group_503039759_2" class=3D"m_1749352385756662461ss-q-checkbox">
</span>
<span class=3D"m_1749352385756662461ss-choice-label">
TENS</span>
</label>
</li>
 <li class=3D"m_1749352385756662461ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_1749352385756662461ss-choice-item-control m_1749352385756662461goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id==3D"m_1749352385756662461group_503039759_3" class=3D"m_1749352385756662461ss-q-checkbox">
</span>
<span class=3D"m_1749352385756662461ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
 <li class=3D"m_1749352385756662461ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_1749352385756662461ss-choice-item-control m_1749352385756662461goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"KINESIOLOGO" id=3D"m_1749352385756662461group_503039759_4" class=3D"m_1749352385756662461ss-q-checkbox">
</span>
<span class=3D"m_1749352385756662461ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
 <li class=3D"m_1749352385756662461ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_1749352385756662461ss-choice-item-control m_1749352385756662461goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"PSICOLOGO" id=3D"m_1749352385756662461group_503039759_5" class=3D"m_1749352385756662461ss-q-checkbox">
</span>
<span class=3D"m_1749352385756662461ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_1749352385756662461errorbox-good">
<div dir=3D"auto" class=3D"m_1749352385756662461ss-item m_1749352385756662461ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_1749352385756662461ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_1749352385756662461ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_1749352385756662461ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
</form>
</div>
</div>
</td>
</tr>
<tr height=3D"24px">
</tr>
</tbody>
</table>
</div>
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"max-width:672px;min-width:154px" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242;font-size:13px" target=3D"_blank">
Crea tu propio formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
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