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<br>
---- Mensaje original ----<br>
Asunto: Registro de Atención Domiciliaria Oncovida<br>
Enviado: 26-04-2019 11:34<br>
De: Formularios de Google &lt;forms-receipts-noreply@google.com&gt;<br>
Para: jenniferolivares@telemed-chile.cl<br>
Cc: <br>
<br>
<table border="0" cellpadding="0" cellspacing="0" style="background-color:rgb(38,4,154);" width="100%" role="presentation">
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<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%" role="presentation">
<tbody>
<tr height="24px">
<td>
</td>
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<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=mail_form_link">
Registro de Atención Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height="12px">
</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 class="ss-form-container" style="">
<div class="ss-form-heading" style="">
<h1 class="ss-form-title" dir="ltr" style="margin:.67em 0;">
Registro de Atención Domiciliaria Oncovida</h1>

<div class="ss-form-desc ss-no-ignore-whitespace" 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 class="ss-form" style="">
<form action="" method="GET" id="ss-form" style="">
<br>

<div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class="ss-q-item-label" for="emailAddress" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Dirección de correo electrónico
<label for="emailAddress" aria-label="(Campo obligatorio)" style="">
</label>

<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>
</label>

<div class="ss-q-text ss-printable-text-line" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
<a href="mailto:jenniferolivares@telemed-chile.cl">
jenniferolivares@telemed-chile.cl</a>
</div>



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

<div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-embeddable-object-container" style="margin:12px 0;max-width:100%;position:relative;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

<h2 class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
</h2>

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

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

<br>
 <div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-page-break" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

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

<div class="ss-page-description ss-no-ignore-whitespace" dir="auto" style="white-space:pre-wrap;word-wrap:break-word;">
Aquí debe ingresar sus datos personales</div>

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

<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

<label class="ss-q-item-label" for="entry_579114469" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Primer Nombre y Apellido Paterno
<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>

<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>


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



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

<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

<label class="ss-q-item-label" for="entry_1276273985" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
RUT
<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>

<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: <a href="tel:5632200">
5632200</a>
-k)</div>
</label>


<div class="ss-q-text" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
<a href="tel:17773258-3">
17773258-3</a>
</div>



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

<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-select" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

<label class="ss-q-item-label" for="entry_133691676" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Tipo
<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>

<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
Si asisten más de 1 prestador simultáneamente, cada uno debe hacer un registro independiente</div>
</label>


<select name="entry.133691676" disabled id="entry_133691676" aria-label="Tipo Si asisten más de 1 prestador simultáneamente, cada uno debe hacer un registro independiente " aria-required="true" style="">
<option value="" style="">
</option>

<option value="MEDICO" disabled style="">
MEDICO</option>
 <option value="ENFERMERA/O" disabled selected style="">
ENFERMERA/O</option>
 <option value="TENS" disabled style="">
TENS</option>
 <option value="KINESIOLOGA/O" disabled style="">
KINESIOLOGA/O</option>
 <option value="PSICOLOGO" disabled style="">
PSICOLOGO</option>
 <option value="NUTRICIONISTA" disabled style="">
NUTRICIONISTA</option>
</select>

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

<br>
 <div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-embeddable-object-container" style="margin:12px 0;max-width:100%;position:relative;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

<h2 class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
</h2>

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

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

<br>
 <div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-page-break" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

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

<div class="ss-page-description ss-no-ignore-whitespace" 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 class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-section-header" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

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

<div class="ss-section-description ss-no-ignore-whitespace" style="margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word;">
</div>

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

<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

<label class="ss-q-item-label" for="entry_823811303" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Ingrese el Rut del Paciente
<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>

<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: <a href="tel:5632200">
5632200</a>
-k)</div>
</label>


<div class="ss-q-text" dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%;">
<a href="tel:16611779">
16611779</a>
-K</div>



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

<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

<label class="ss-q-item-label" for="entry_1959365839" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Ingrese el Primer Nombre y Apellido Paterno del Paciente
<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>

<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>


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



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

<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-select" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

<label class="ss-q-item-label" for="entry_545002227" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Previsión
<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>

<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>


<select name="entry.545002227" disabled id="entry_545002227" aria-label="Previsión  " aria-required="true" style="">
<option value="" style="">
</option>

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

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

<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

<label class="ss-q-item-label" for="entry_1900161356" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Ciudad
<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>

<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>


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



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

<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-text" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

<label class="ss-q-item-label" for="entry_1298871758" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Comuna
<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>

<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>


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



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

<br>
 <div class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-embeddable-object-container" style="margin:12px 0;max-width:100%;position:relative;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

<h2 class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
</h2>

<div style="text-align: right;">
<img class="ss-image" title="" 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 class="errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-page-break" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

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

<div class="ss-page-description ss-no-ignore-whitespace" 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 class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-radio" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

<label class="ss-q-item-label" for="entry_2073233714" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Tipo de Atención
<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>

<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>



<ul class="ss-choices" role="radiogroup" aria-label="Tipo de Atención  " style="list-style:none;padding:0;margin:.5em 0 0;">
<li class="ss-choice-item" style="margin:0;line-height:1.3em;padding-bottom:.5em;">

<label>
<span class="ss-choice-item-control goog-inline-block" style="position:relative;display:inline-block;">
<input type="radio" name="entry.1222378237" disabled checked value="Domicilio" id="group_1222378237_1" role="radio" class="ss-q-radio" aria-label="Domicilio" aria-required="true" style="">
</span>

<span class="ss-choice-label" style="">
Domicilio</span>

</label>
</li>
 <li class="ss-choice-item" style="margin:0;line-height:1.3em;padding-bottom:.5em;">

<label>
<span class="ss-choice-item-control goog-inline-block" style="position:relative;display:inline-block;">
<input type="radio" name="entry.1222378237" disabled value="Ambulatorio" id="group_1222378237_2" role="radio" class="ss-q-radio" aria-label="Ambulatorio" aria-required="true" style="">
</span>

<span class="ss-choice-label" style="">
Ambulatorio</span>

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


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

<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-date" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

<label class="ss-q-item-label" for="entry_1705849412" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Fecha de la Atención
<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>

<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>


<div class="ss-q-date" role="group" aria-label="Fecha de la Atención  " style="">
<div class="ss-datetime-box goog-inline-block" role="group" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;position:relative;display:inline-block;">
 <select name="entry.1705849412_day" disabled class="ss-day-dropdown" id="entry.1705849412_day" aria-label="Día del mes" aria-required="true" style="">
<option value="" style="">
Día</option>

<option value="1" style="">
1</option>
 <option value="2" style="">
2</option>
 <option value="3" style="">
3</option>
 <option value="4" style="">
4</option>
 <option value="5" style="">
5</option>
 <option value="6" style="">
6</option>
 <option value="7" style="">
7</option>
 <option value="8" style="">
8</option>
 <option value="9" style="">
9</option>
 <option value="10" style="">
10</option>
 <option value="11" style="">
11</option>
 <option value="12" style="">
12</option>
 <option value="13" style="">
13</option>
 <option value="14" style="">
14</option>
 <option value="15" style="">
15</option>
 <option value="16" style="">
16</option>
 <option value="17" style="">
17</option>
 <option value="18" style="">
18</option>
 <option value="19" style="">
19</option>
 <option value="20" style="">
20</option>
 <option value="21" style="">
21</option>
 <option value="22" style="">
22</option>
 <option value="23" style="">
23</option>
 <option value="24" selected style="">
24</option>
 <option value="25" style="">
25</option>
 <option value="26" style="">
26</option>
 <option value="27" style="">
27</option>
 <option value="28" style="">
28</option>
 <option value="29" style="">
29</option>
 <option value="30" style="">
30</option>
 <option value="31" style="">
31</option>
</select>
   <select name="entry.1705849412_month" disabled class="ss-month-dropdown" id="entry.1705849412_month" aria-label="Mes" aria-required="true" style="">
<option value="" style="">
Mes</option>

<option value="1" style="">
enero</option>
 <option value="2" style="">
febrero</option>
 <option value="3" style="">
marzo</option>
 <option value="4" selected style="">
abril</option>
 <option value="5" style="">
mayo</option>
 <option value="6" style="">
junio</option>
 <option value="7" style="">
julio</option>
 <option value="8" style="">
agosto</option>
 <option value="9" style="">
septiembre</option>
 <option value="10" style="">
octubre</option>
 <option value="11" style="">
noviembre</option>
 <option value="12" style="">
diciembre</option>
</select>
 
<select name="entry.1705849412_year" disabled id="entry.1705849412_year" aria-label="Año" aria-required="true" style="">
<option value="" style="">
Año</option>

<option value="1896" style="">
1896</option>
 <option value="1897" style="">
1897</option>
 <option value="1898" style="">
1898</option>
 <option value="1899" style="">
1899</option>
 <option value="1900" style="">
1900</option>
 <option value="1901" style="">
1901</option>
 <option value="1902" style="">
1902</option>
 <option value="1903" style="">
1903</option>
 <option value="1904" style="">
1904</option>
 <option value="1905" style="">
1905</option>
 <option value="1906" style="">
1906</option>
 <option value="1907" style="">
1907</option>
 <option value="1908" style="">
1908</option>
 <option value="1909" style="">
1909</option>
 <option value="1910" style="">
1910</option>
 <option value="1911" style="">
1911</option>
 <option value="1912" style="">
1912</option>
 <option value="1913" style="">
1913</option>
 <option value="1914" style="">
1914</option>
 <option value="1915" style="">
1915</option>
 <option value="1916" style="">
1916</option>
 <option value="1917" style="">
1917</option>
 <option value="1918" style="">
1918</option>
 <option value="1919" style="">
1919</option>
 <option value="1920" style="">
1920</option>
 <option value="1921" style="">
1921</option>
 <option value="1922" style="">
1922</option>
 <option value="1923" style="">
1923</option>
 <option value="1924" style="">
1924</option>
 <option value="1925" style="">
1925</option>
 <option value="1926" style="">
1926</option>
 <option value="1927" style="">
1927</option>
 <option value="1928" style="">
1928</option>
 <option value="1929" style="">
1929</option>
 <option value="1930" style="">
1930</option>
 <option value="1931" style="">
1931</option>
 <option value="1932" style="">
1932</option>
 <option value="1933" style="">
1933</option>
 <option value="1934" style="">
1934</option>
 <option value="1935" style="">
1935</option>
 <option value="1936" style="">
1936</option>
 <option value="1937" style="">
1937</option>
 <option value="1938" style="">
1938</option>
 <option value="1939" style="">
1939</option>
 <option value="1940" style="">
1940</option>
 <option value="1941" style="">
1941</option>
 <option value="1942" style="">
1942</option>
 <option value="1943" style="">
1943</option>
 <option value="1944" style="">
1944</option>
 <option value="1945" style="">
1945</option>
 <option value="1946" style="">
1946</option>
 <option value="1947" style="">
1947</option>
 <option value="1948" style="">
1948</option>
 <option value="1949" style="">
1949</option>
 <option value="1950" style="">
1950</option>
 <option value="1951" style="">
1951</option>
 <option value="1952" style="">
1952</option>
 <option value="1953" style="">
1953</option>
 <option value="1954" style="">
1954</option>
 <option value="1955" style="">
1955</option>
 <option value="1956" style="">
1956</option>
 <option value="1957" style="">
1957</option>
 <option value="1958" style="">
1958</option>
 <option value="1959" style="">
1959</option>
 <option value="1960" style="">
1960</option>
 <option value="1961" style="">
1961</option>
 <option value="1962" style="">
1962</option>
 <option value="1963" style="">
1963</option>
 <option value="1964" style="">
1964</option>
 <option value="1965" style="">
1965</option>
 <option value="1966" style="">
1966</option>
 <option value="1967" style="">
1967</option>
 <option value="1968" style="">
1968</option>
 <option value="1969" style="">
1969</option>
 <option value="1970" style="">
1970</option>
 <option value="1971" style="">
1971</option>
 <option value="1972" style="">
1972</option>
 <option value="1973" style="">
1973</option>
 <option value="1974" style="">
1974</option>
 <option value="1975" style="">
1975</option>
 <option value="1976" style="">
1976</option>
 <option value="1977" style="">
1977</option>
 <option value="1978" style="">
1978</option>
 <option value="1979" style="">
1979</option>
 <option value="1980" style="">
1980</option>
 <option value="1981" style="">
1981</option>
 <option value="1982" style="">
1982</option>
 <option value="1983" style="">
1983</option>
 <option value="1984" style="">
1984</option>
 <option value="1985" style="">
1985</option>
 <option value="1986" style="">
1986</option>
 <option value="1987" style="">
1987</option>
 <option value="1988" style="">
1988</option>
 <option value="1989" style="">
1989</option>
 <option value="1990" style="">
1990</option>
 <option value="1991" style="">
1991</option>
 <option value="1992" style="">
1992</option>
 <option value="1993" style="">
1993</option>
 <option value="1994" style="">
1994</option>
 <option value="1995" style="">
1995</option>
 <option value="1996" style="">
1996</option>
 <option value="1997" style="">
1997</option>
 <option value="1998" style="">
1998</option>
 <option value="1999" style="">
1999</option>
 <option value="2000" style="">
2000</option>
 <option value="2001" style="">
2001</option>
 <option value="2002" style="">
2002</option>
 <option value="2003" style="">
2003</option>
 <option value="2004" style="">
2004</option>
 <option value="2005" style="">
2005</option>
 <option value="2006" style="">
2006</option>
 <option value="2007" style="">
2007</option>
 <option value="2008" style="">
2008</option>
 <option value="2009" style="">
2009</option>
 <option value="2010" style="">
2010</option>
 <option value="2011" style="">
2011</option>
 <option value="2012" style="">
2012</option>
 <option value="2013" style="">
2013</option>
 <option value="2014" style="">
2014</option>
 <option value="2015" style="">
2015</option>
 <option value="2016" selected style="">
2016</option>
 <option value="2017" style="">
2017</option>
 <option value="2018" style="">
2018</option>
 <option value="2019" style="">
2019</option>
 <option value="2020" style="">
2020</option>
 <option value="2021" style="">
2021</option>
 <option value="2022" style="">
2022</option>
 <option value="2023" style="">
2023</option>
 <option value="2024" style="">
2024</option>
 <option value="2025" style="">
2025</option>
 <option value="2026" style="">
2026</option>
 <option value="2027" style="">
2027</option>
 <option value="2028" style="">
2028</option>
 <option value="2029" style="">
2029</option>
 <option value="2030" style="">
2030</option>
 <option value="2031" style="">
2031</option>
 <option value="2032" style="">
2032</option>
 <option value="2033" style="">
2033</option>
 <option value="2034" style="">
2034</option>
 <option value="2035" style="">
2035</option>
 <option value="2036" style="">
2036</option>
 <option value="2037" style="">
2037</option>
 <option value="2038" style="">
2038</option>
 <option value="2039" style="">
2039</option>
 <option value="2040" style="">
2040</option>
 <option value="2041" style="">
2041</option>
 <option value="2042" style="">
2042</option>
 <option value="2043" style="">
2043</option>
 <option value="2044" style="">
2044</option>
 <option value="2045" style="">
2045</option>
 <option value="2046" style="">
2046</option>
 <option value="2047" style="">
2047</option>
 <option value="2048" style="">
2048</option>
 <option value="2049" style="">
2049</option>
 <option value="2050" style="">
2050</option>
 <option value="2051" style="">
2051</option>
 <option value="2052" style="">
2052</option>
 <option value="2053" style="">
2053</option>
 <option value="2054" style="">
2054</option>
 <option value="2055" style="">
2055</option>
 <option value="2056" style="">
2056</option>
 <option value="2057" style="">
2057</option>
 <option value="2058" style="">
2058</option>
 <option value="2059" style="">
2059</option>
 <option value="2060" style="">
2060</option>
 <option value="2061" style="">
2061</option>
 <option value="2062" style="">
2062</option>
 <option value="2063" style="">
2063</option>
 <option value="2064" style="">
2064</option>
 <option value="2065" style="">
2065</option>
 <option value="2066" style="">
2066</option>
 <option value="2067" style="">
2067</option>
 <option value="2068" style="">
2068</option>
 <option value="2069" style="">
2069</option>
</select>

</div>

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

<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">

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

<label class="ss-q-item-label" for="entry_206244955" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Hora de la Atención
<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>

<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>


<div class="ss-q-time" style="">
<div class="ss-datetime-box goog-inline-block" dir="ltr" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;position:relative;display:inline-block;">
<select name="entry.206244955_hour" disabled id="entry.206244955_hour" aria-label="Hora" aria-required="true" style="">
<option value="" style="">
h</option>

<option value="00" style="">
00</option>
 <option value="01" style="">
01</option>
 <option value="02" style="">
02</option>
 <option value="03" style="">
03</option>
 <option value="04" style="">
04</option>
 <option value="05" style="">
05</option>
 <option value="06" style="">
06</option>
 <option value="07" style="">
07</option>
 <option value="08" style="">
08</option>
 <option value="09" style="">
09</option>
 <option value="10" style="">
10</option>
 <option value="11" style="">
11</option>
 <option value="12" style="">
12</option>
 <option value="13" style="">
13</option>
 <option value="14" style="">
14</option>
 <option value="15" style="">
15</option>
 <option value="16" style="">
16</option>
 <option value="17" style="">
17</option>
 <option value="18" style="">
18</option>
 <option value="19" style="">
19</option>
 <option value="20" style="">
20</option>
 <option value="21" selected style="">
21</option>
 <option value="22" style="">
22</option>
 <option value="23" style="">
23</option>
</select>

:
<select name="entry.206244955_minute" disabled id="entry.206244955_minute" aria-label="Minuto" aria-required="true" style="">
<option value="" style="">
min</option>

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



<div class="ss-datetime-box-spacer goog-inline-block" style="height:32px;vertical-align:middle;position:relative;display:inline-block;">
</div>
</div>
</div>
</div>
</div>
</div>

<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item ss-item-required ss-select" style="margin:12px 0;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

<label class="ss-q-item-label" for="entry_1747608258" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Performance Status ECOG del Paciente
<label for="itemView.getDomIdToLabel()" aria-label="(Campo obligatorio)" style="">
</label>

<span class="ss-required-asterisk" aria-hidden="true" style="color:#c43b1d;">
*</span>
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>


<select name="entry.1747608258" disabled id="entry_1747608258" aria-label="Performance Status ECOG del Paciente  " aria-required="true" style="">
<option value="" style="">
</option>

<option value="0" disabled style="">
0</option>
 <option value="1" disabled style="">
1</option>
 <option value="2" disabled style="">
2</option>
 <option value="3" disabled selected style="">
3</option>
 <option value="4" disabled style="">
4</option>
</select>

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

<br>
 <div class="ss-form-question errorbox-good" role="listitem" style="">

<div dir="auto" class="ss-item  ss-scale" style="margin:12px 0;overflow-x:auto;">
<div class="ss-form-entry" style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">

<label class="ss-q-item-label" for="entry_1716090865" style="">
<div class="ss-q-title" style="display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
Escala Dolor EVA Actual
</div>

<div class="ss-q-help ss-secondary-text" dir="auto" style="display:block;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>



<table border="0" cellpadding="5" cellspacing="0" id="entry_1421689035" style="">
<tr aria-hidden="true" style="">
<td class="ss-scalenumbers" style="text-align:center;">
</td>

<td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_1" style="display:block;padding:0.5em 0 .5em;">
0</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_2" style="display:block;padding:0.5em 0 .5em;">
1</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_3" style="display:block;padding:0.5em 0 .5em;">
2</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_4" style="display:block;padding:0.5em 0 .5em;">
3</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_5" style="display:block;padding:0.5em 0 .5em;">
4</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_6" style="display:block;padding:0.5em 0 .5em;">
5</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_7" style="display:block;padding:0.5em 0 .5em;">
6</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_8" style="display:block;padding:0.5em 0 .5em;">
7</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_9" style="display:block;padding:0.5em 0 .5em;">
8</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_10" style="display:block;padding:0.5em 0 .5em;">
9</label>
</td>
 <td class="ss-scalenumbers" style="text-align:center;">
<label class="ss-scalenumber" for="group_1421689035_11" style="display:block;padding:0.5em 0 .5em;">
10</label>
</td>

<td class="ss-scalenumbers" style="text-align:center;">
</td>
</tr>

<tr role="radiogroup" aria-label="Escala Dolor EVA Actual  Selecciona un valor en el intervalo de 0 a 10 ." style="">
<td class="ss-scalerow ss-leftlabel" style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0;">
<div aria-hidden="true" class="aria-todo" style="">
</div>
</td>

<td class="ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell" style="">
<input type="radio" name="entry.1421689035" disabled value="0" id="group_1421689035_1" role="radio" class="ss-q-radio" aria-label="0" style="">
</div>
</td>
 <td class="ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell" style="">
<input type="radio" name="entry.1421689035" disabled value="1" id="group_1421689035_2" role="radio" class="ss-q-radio" aria-label="1" style="">
</div>
</td>
 <td class="ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell" style="">
<input type="radio" name="entry.1421689035" disabled value="2" id="group_1421689035_3" role="radio" class="ss-q-radio" aria-label="2" style="">
</div>
</td>
 <td class="ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell" style="">
<input type="radio" name="entry.1421689035" disabled value="3" id="group_1421689035_4" role="radio" class="ss-q-radio" aria-label="3" style="">
</div>
</td>
 <td class="ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell" style="">
<input type="radio" name="entry.1421689035" disabled value="4" id="group_1421689035_5" role="radio" class="ss-q-radio" aria-label="4" style="">
</div>
</td>
 <td class="ss-scalerow" style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class="ss-scalerow-fieldcell" style="">
<input type="radio" name="entry.1421689035" disabled checked value="5" id="group_1421689035_6" role="radio" class="ss-q-radio" aria-label="5" style="">
</div>
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Paciente masculino de 35 años con diagnóstico actual de Gioblastoma Grado IV. En la ultima visita programada, se observa rápida progresión de síntomas, a la evaluación difícil despertar, glasgow 9 pts, RO 3 RV 1 RM 5. Mayor compromiso motor y mayor dificultad para deglutir, poca tolerancia a líquidos por exceso de tos, aun tolerando medicamentos por boca, no logra deambular se sienta en silla de ruedas con ayuda pero la mayoría del tiempo se mantiene encamado. 
Madre refiere episodios de cefalea que ceden a la administración de paracetamol, con frecuencia de dos episodios semanales. Medico que acude a domicilio refiere que por condición actual necesita instalación de sonda nasograstrica.
Se realiza visita domiciliaria SOS. A la evaluación glasgow 10 pts RO 2 RV 2 RM 6, muy quejumbroso, sin respuesta al paracetamol. Clinicamente trastorno deglutorio leve a moderado, tos no efectiva, con somnolencia que dificulta administración de tratamiento y correcta nutrición. Padres refieren mayor dificultad en la movilización por espasticidad. 
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A la evaluación ocular presenta desviación de la mirada hacia abajo. pupilas isocoricas, reflejo foto motor positivo. Tórax simétrico estertores húmedos a derecha.  escapulas sanas, abdomen blando depresible. 
Hemiplejia derecha, con espasticidad, hemicuerpo izquierdo sin conflicto en la movilización logra vencer gravedad, zona sacra sana y genital sana, enrojecimiento en talón derecho que no aumenta desde la ultima visita, pie equino.  </div>



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 Gioblastoma Grado IV</div>



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-Instalación de sonda nasogastrica por presentar clinicamente trastorno 
 deglutorio y de esta manera disminuir el riesgo de broncoaspiracion y facilitad 
 la administración de fármacos.
- Educación sobre cuidados de la sonda nasogastrica. 
- Educación respecto a la administración de tratamiento por sonda nasogastrica.
- Educación en cuanto a conductas para evitar riesgo de broncoaspiración. 
- Refuerzo sobre cuidados de la piel y cambios de posición.
- Se solicita evaluación por Kinesiologo para apoyo kinesico motor domiciliario.
- Se solicita apoyo psicológico.
- Evaluación por medico y enfermera.
- Cambio de tratamiento farmacológico para manejo del dolor. 
- Especificación sobre identificación de situaciones que necesiten manejo de 
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Levetiracetam 1gr c/12
Dexametasona 4 mg día 
Omeprazol 20 mg día 
Paracetamol 1 gr SOS. 
Tramal en gotas SOS </div>



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1898</option>
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1899</option>
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