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Sandra Maulen Angel EU</div>
<div dir=3D"ltr">
<br>
Inicio del mensaje re=enviado:<br>
<br>
</div>
<blockquote type=3D"cite">
<div dir=3D"ltr">
<b>
De:</b>
 =Formularios de Google &lt;<a href=3D"mailto:forms-receipts-noreply@google.co=m">
forms-receipts-noreply@google.com</a>
&gt;<br>
<b>
Fecha:</b>
 15 de mayo de 2=019, 11:38:24 CLT<br>
<b>
Para:</b>
 <a href=3D"mailto:SANDRAMAULENANGEL@GMAIL.=COM">
SANDRAMAULENANGEL@GMAIL.COM</a>
<br>
<b>
Asunto:</b>
 <b>
Registro de Atenci==C3=B3n Domiciliaria Oncovida</b>
<br>
<br>
</div>
</blockquote>
<blockquote type==3D"cite">
<div dir=3D"ltr">
<table border=3D"0" cellpadding=3D"0" cellspacing==3D"0" style=3D"background-color:rgb(38,4,154);" width=3D"100%" role=3D"pres=entation">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left: 24px">
<img a=lt=3D"Formularios de Google" height=3D"26px" style=3D"display: inline-block;= margin: 0; vertical-align: middle;" width=3D"143px" src=3D"https://www.gsta=tic.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"backg=round-color: #fff;" width=3D"100%" role=3D"presentation">
<tbody>
<tr height=3D="24px">
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<div style=3D"font-size: 13px; line-height: 18p=x; color: #424242; font-weight: 700">
Gracias por llenar <a href=3D"https://d=ocs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpP=co75w/viewform?usp=3Dmail_form_link">
Registro de Atenci=C3=B3n Domiciliaria O=ncovida</a>
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<div style=3D"fo=nt-size: 13px; line-height: 18px; color: #424242;">
Estas son tus respuestas:=</div>
</td>
</tr>
<tr>
<td>
<div class=3D"ss-form-container" style=3D"">
<div cla=ss=3D"ss-form-heading" style=3D"">
<h1 class=3D"ss-form-title" dir=3D"ltr" st=yle=3D"margin:.67em 0;">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
=<div class=3D"ss-form-desc ss-no-ignore-whitespace" style=3D"font:inherit;wi=dth:99%;margin:0 0 1em;white-space:pre-wrap;word-wrap:break-word;">
Este es e=l sistema de registro de atenciones domiciliarias de Oncovida.   Debe ser ll=enado por el prestador individual, y debe realizarse un registro por cada vi=sita 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"ss-form" style=3D"">
<form action=3D"" method=3D"GET" id=3D"ss-=form" style=3D"">
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical=-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss=-q-item-label" for=3D"emailAddress" style=3D"">
<div class=3D"ss-q-title" sty=le=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em;">
=Direcci=C3=B3n de correo electr=C3=B3nico<label for=3D"emailAddress" aria-label=3D"(Campo obligatorio)" style=3D"">
</=label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
</label>
<div class=3D"ss-q-text ss-printable-text-line" dir=3D"auto" style=3D"backgr=ound-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-spa=ce:pre-wrap;color:#545454;width:70%;">
<a href=3D"mailto:SANDRAMAULENANGEL@GM=AIL.COM">
SANDRAMAULENANGEL@GMAIL.COM</a>
</div>
</div>
</div>
</div>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style=3D="margin:12px 0;max-width:100%;position:relative;">
<div class=3D"ss-form-entr=y" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-t=op:0;max-width:100%;">
<h2 class=3D"ss-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"ss-image" title=3D"" src=3D"=https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGh=VlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width: 78px;outline:none;" alt=3D="Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0;">
=<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:mid=dle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class=3D"ss-page-title" style=3D"margin:2em -0.4em 0;padding:0.4em;backg=round-color:#eee;">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" dir=3D"auto" styl=e=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"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical=-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_579114469" style=3D"">
<div cla=ss=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;m=argin-bottom:.83em;">
Primer Nombre y Apellido Paterno<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
SANDRA MAULEN </div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical=-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_1276273985" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
RUT<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
RUT con Gui=C3=B3n y D=C3=ADgito Verif=icador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
16621429-7</div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-select" style=3D"marg=in:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertic=al-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_133691676" style=3D"">
<div cla=ss=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;m=argin-bottom:.83em;">
Tipo<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
Si asisten m=C3=A1s de 1 prestador sim=ult=C3=A1neamente, cada uno debe hacer un registro independiente</div>
</labe=l>
<select name=3D"entry.133691676" disabled=3D"" id=3D"entry_133691676" aria-l=abel=3D"Tipo Si asisten m=C3=A1s de 1 prestador simult=C3=A1neamente, cada u=no debe hacer un registro independiente " aria-required=3D"true" style=3D"">
=<option value=3D"" style=3D"">
</option>
<option value=3D"MEDICO" disabled=3D"" style=3D"">
MEDICO</option>
 <option va=lue=3D"ENFERMERA/O" disabled=3D"" selected=3D"" style=3D"">
ENFERMERA/O</opti=on>
 <option value=3D"TENS" disabled=3D"" style=3D"">
TENS</option>
 <option va=lue=3D"KINESIOLOGA/O" disabled=3D"" style=3D"">
KINESIOLOGA/O</option>
 <optio=n value=3D"PSICOLOGO" disabled=3D"" style=3D"">
PSICOLOGO</option>
 <option va=lue=3D"NUTRICIONISTA" disabled=3D"" style=3D"">
NUTRICIONISTA</option>
</selec=t>
</div>
</div>
</div>
<br>
 <div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style=3D="margin:12px 0;max-width:100%;position:relative;">
<div class=3D"ss-form-entr=y" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-t=op:0;max-width:100%;">
<h2 class=3D"ss-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"ss-image" title=3D"" src=3D"=https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lS=Ci4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width: 78px;outline:none;" alt=3D="Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0;">
=<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:mid=dle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class=3D"ss-page-title" style=3D"margin:2em -0.4em 0;padding:0.4em;backg=round-color:#eee;">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" dir=3D"auto" styl=e=3D"white-space:pre-wrap;word-wrap:break-word;">
En esta secci=C3=B3n debe i=ngresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
 <div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-section-header" style=3D"margin:12px 0=;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:=middle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class=3D"ss-section-title" style=3D"background-color:#eee;padding:0.4em;=margin:2em -0.4em 0;">
Datos Personales del Paciente</h2>
<div class=3D"ss-section-description ss-no-ignore-whitespace" style=3D"margi=n-top:0.5em;white-space:pre-wrap;word-wrap:break-word;">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical=-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_823811303" style=3D"">
<div cla=ss=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;m=argin-bottom:.83em;">
Ingrese el Rut del Paciente<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
RUT con Gui=C3=B3n y D=C3=ADgito Verif=icador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
5262054-6</div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical=-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_1959365839" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Ingrese el Primer Nombre y Apellido Paterno del Pacien=te<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
JUANA CERENIC </div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-select" style=3D"marg=in:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertic=al-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_545002227" style=3D"">
<div cla=ss=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;m=argin-bottom:.83em;">
Previsi=C3=B3n<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<select name=3D"entry.545002227" disabled=3D"" id=3D"entry_545002227" aria-l=abel=3D"Previsi=C3=B3n  " aria-required=3D"true" style=3D"">
<option value=3D="" style=3D"">
</option>
<option value=3D"BANMEDICA" disabled=3D"" style=3D"">
BANMEDICA</option>
 <opt=ion value=3D"CAPREDENA" disabled=3D"" style=3D"">
CAPREDENA</option>
 <option v=alue=3D"COLMENA" disabled=3D"" style=3D"">
COLMENA</option>
 <option value=3D"=CONSALUD" disabled=3D"" style=3D"">
CONSALUD</option>
 <option value=3D"CRUZ B=LANCA" disabled=3D"" style=3D"">
CRUZ BLANCA</option>
 <option value=3D"DIPREC=A" disabled=3D"" style=3D"">
DIPRECA</option>
 <option value=3D"FONASA" disabl=ed=3D"" style=3D"">
FONASA</option>
 <option value=3D"FUNDACION" disabled=3D""= style=3D"">
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled=3D="" selected=3D"" style=3D"">
ISAPRES DEL COBRE</option>
 <option value=3D"NUEV=A MASVIDA" disabled=3D"" style=3D"">
NUEVA MASVIDA</option>
 <option value=3D"=VIDATRES" disabled=3D"" style=3D"">
VIDATRES</option>
 <option value=3D"PARTIC=ULAR" disabled=3D"" style=3D"">
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical=-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_1900161356" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Ciudad<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
OLMUE </div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin=:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical=-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_1298871758" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Comuna<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
OLMUE </div>
</div>
</div>
</div>
<br>
 <div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style=3D="margin:12px 0;max-width:100%;position:relative;">
<div class=3D"ss-form-entr=y" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-t=op:0;max-width:100%;">
<h2 class=3D"ss-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"ss-image" title=3D"" src=3D"=https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn=1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width: 78px;outline:none;" alt=3D="Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0;">
=<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:mid=dle;margin-left:0;margin-top:0;max-width:100%;">
<h2 class=3D"ss-page-title" style=3D"margin:2em -0.4em 0;padding:0.4em;backg=round-color:#eee;">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" dir=3D"auto" styl=e=3D"white-space:pre-wrap;word-wrap:break-word;">
En esta secci=C3=B3n debe i=ngresar los datos de la atenci=C3=B3n domiciliaria</div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-radio" style=3D"margi=n:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertica=l-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_2073233714" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Tipo de Atenci=C3=B3n<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<ul class=3D"ss-choices" role=3D"radiogroup" aria-label=3D"Tipo de Atenci=C3==B3n  " style=3D"list-style:none;padding:0;margin:.5em 0 0;">
<li class=3D"ss=-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em;">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"pos=ition:relative;display:inline-block;">
<input type=3D"radio" name=3D"entry.12=22378237" disabled=3D"" checked=3D"" value=3D"Domicilio" id=3D"group_1222378=237_1" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"Domicilio" aria-req=uired=3D"true" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
Domicilio</span>
</label>
</li>
 <li class=3D"ss-choice-item" style=3D"margin:0;line-height:1.3=em;padding-bottom:.5em;">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"pos=ition:relative;display:inline-block;">
<input type=3D"radio" name=3D"entry.12=22378237" disabled=3D"" value=3D"Ambulatorio" id=3D"group_1222378237_2" role==3D"radio" class=3D"ss-q-radio" aria-label=3D"Ambulatorio" aria-required=3D"=true" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-date" style=3D"margin=:12px 0;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical=-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_1705849412" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Fecha de la Atenci=C3=B3n<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"ss-q-date" role=3D"group" aria-label=3D"Fecha de la Atenci=C3=B3=n  " style=3D"">
<div class=3D"ss-datetime-box goog-inline-block" role=3D"gro=up" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;paddi=ng-left:3px;vertical-align:middle;margin:4px 3px;position:relative;display:i=nline-block;">
 <select name=3D"entry.1705849412_month" disabled=3D"" class=3D="ss-month-dropdown" id=3D"entry.1705849412_month" aria-label=3D"Mes" aria-re=quired=3D"true" style=3D"">
<option value=3D"" style=3D"">
Mes</option>
<option value=3D"1" style=3D"">
enero</option>
 <option value=3D"2" style=3D""=>
febrero</option>
 <option value=3D"3" style=3D"">
marzo</option>
 <option valu=e=3D"4" style=3D"">
abril</option>
 <option value=3D"5" selected=3D"" style=3D="">
mayo</option>
 <option value=3D"6" style=3D"">
junio</option>
 <option value==3D"7" style=3D"">
julio</option>
 <option value=3D"8" style=3D"">
agosto</opti=on>
 <option value=3D"9" style=3D"">
septiembre</option>
 <option value=3D"10" s=tyle=3D"">
octubre</option>
 <option value=3D"11" style=3D"">
noviembre</option=>
 <option value=3D"12" style=3D"">
diciembre</option>
</select>
   <select name==3D"entry.1705849412_day" disabled=3D"" class=3D"ss-day-dropdown" id=3D"entr=y.1705849412_day" aria-label=3D"D=C3=ADa del mes" aria-required=3D"true" sty=le=3D"">
<option value=3D"" style=3D"">
D=C3=ADa</option>
<option value=3D"1" style=3D"">
1</option>
 <option value=3D"2" style=3D"">
2</=option>
 <option value=3D"3" style=3D"">
3</option>
 <option value=3D"4" style=3D="">
4</option>
 <option value=3D"5" style=3D"">
5</option>
 <option value=3D"6" s=tyle=3D"">
6</option>
 <option value=3D"7" style=3D"">
7</option>
 <option value==3D"8" style=3D"">
8</option>
 <option value=3D"9" style=3D"">
9</option>
 <opti=on value=3D"10" style=3D"">
10</option>
 <option value=3D"11" style=3D"">
11</o=ption>
 <option value=3D"12" style=3D"">
12</option>
 <option value=3D"13" styl=e=3D"">
13</option>
 <option value=3D"14" selected=3D"" style=3D"">
14</option>
= <option value=3D"15" style=3D"">
15</option>
 <option value=3D"16" style=3D""=>
16</option>
 <option value=3D"17" style=3D"">
17</option>
 <option value=3D"18=" style=3D"">
18</option>
 <option value=3D"19" style=3D"">
19</option>
 <option= value=3D"20" style=3D"">
20</option>
 <option value=3D"21" style=3D"">
21</opt=ion>
 <option value=3D"22" style=3D"">
22</option>
 <option value=3D"23" style=3D="">
23</option>
 <option value=3D"24" style=3D"">
24</option>
 <option value=3D"=25" style=3D"">
25</option>
 <option value=3D"26" style=3D"">
26</option>
 <opti=on value=3D"27" style=3D"">
27</option>
 <option value=3D"28" style=3D"">
28</o=ption>
 <option value=3D"29" style=3D"">
29</option>
 <option value=3D"30" styl=e=3D"">
30</option>
 <option value=3D"31" style=3D"">
31</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled=3D"" id=3D"entry.1705849412_=year" aria-label=3D"A=C3=B1o" aria-required=3D"true" style=3D"">
<option valu=e=3D"" style=3D"">
A=C3=B1o</option>
<option value=3D"1896" style=3D"">
1896</option>
 <option value=3D"1897" style==3D"">
1897</option>
 <option value=3D"1898" style=3D"">
1898</option>
 <option v=alue=3D"1899" style=3D"">
1899</option>
 <option value=3D"1900" style=3D"">
190=0</option>
 <option value=3D"1901" style=3D"">
1901</option>
 <option value=3D"=1902" style=3D"">
1902</option>
 <option value=3D"1903" style=3D"">
1903</optio=n>
 <option value=3D"1904" style=3D"">
1904</option>
 <option value=3D"1905" st=yle=3D"">
1905</option>
 <option value=3D"1906" style=3D"">
1906</option>
 <opti=on value=3D"1907" style=3D"">
1907</option>
 <option value=3D"1908" style=3D""=>
1908</option>
 <option value=3D"1909" style=3D"">
1909</option>
 <option value==3D"1910" style=3D"">
1910</option>
 <option value=3D"1911" style=3D"">
1911</o=ption>
 <option value=3D"1912" style=3D"">
1912</option>
 <option value=3D"1913=" style=3D"">
1913</option>
 <option value=3D"1914" style=3D"">
1914</option>
 <=option value=3D"1915" style=3D"">
1915</option>
 <option value=3D"1916" style=3D="">
1916</option>
 <option value=3D"1917" style=3D"">
1917</option>
 <option val=ue=3D"1918" style=3D"">
1918</option>
 <option value=3D"1919" style=3D"">
1919<=/option>
 <option value=3D"1920" style=3D"">
1920</option>
 <option value=3D"19=21" style=3D"">
1921</option>
 <option value=3D"1922" style=3D"">
1922</option>
= <option value=3D"1923" style=3D"">
1923</option>
 <option value=3D"1924" styl=e=3D"">
1924</option>
 <option value=3D"1925" style=3D"">
1925</option>
 <option= value=3D"1926" style=3D"">
1926</option>
 <option value=3D"1927" style=3D"">
1=927</option>
 <option value=3D"1928" style=3D"">
1928</option>
 <option value=3D="1929" style=3D"">
1929</option>
 <option value=3D"1930" style=3D"">
1930</opti=on>
 <option value=3D"1931" style=3D"">
1931</option>
 <option value=3D"1932" s=tyle=3D"">
1932</option>
 <option value=3D"1933" style=3D"">
1933</option>
 <opt=ion value=3D"1934" style=3D"">
1934</option>
 <option value=3D"1935" style=3D"=">
1935</option>
 <option value=3D"1936" style=3D"">
1936</option>
 <option valu=e=3D"1937" style=3D"">
1937</option>
 <option value=3D"1938" style=3D"">
1938</=option>
 <option value=3D"1939" style=3D"">
1939</option>
 <option value=3D"194=0" style=3D"">
1940</option>
 <option value=3D"1941" style=3D"">
1941</option>
 <=option value=3D"1942" style=3D"">
1942</option>
 <option value=3D"1943" style=3D="">
1943</option>
 <option value=3D"1944" style=3D"">
1944</option>
 <option val=ue=3D"1945" style=3D"">
1945</option>
 <option value=3D"1946" style=3D"">
1946<=/option>
 <option value=3D"1947" style=3D"">
1947</option>
 <option value=3D"19=48" style=3D"">
1948</option>
 <option value=3D"1949" style=3D"">
1949</option>
= <option value=3D"1950" style=3D"">
1950</option>
 <option value=3D"1951" styl=e=3D"">
1951</option>
 <option value=3D"1952" style=3D"">
1952</option>
 <option= value=3D"1953" style=3D"">
1953</option>
 <option value=3D"1954" style=3D"">
1=954</option>
 <option value=3D"1955" style=3D"">
1955</option>
 <option value=3D="1956" style=3D"">
1956</option>
 <option value=3D"1957" style=3D"">
1957</opti=on>
 <option value=3D"1958" style=3D"">
1958</option>
 <option value=3D"1959" s=tyle=3D"">
1959</option>
 <option value=3D"1960" style=3D"">
1960</option>
 <opt=ion value=3D"1961" style=3D"">
1961</option>
 <option value=3D"1962" style=3D"=">
1962</option>
 <option value=3D"1963" style=3D"">
1963</option>
 <option valu=e=3D"1964" style=3D"">
1964</option>
 <option value=3D"1965" style=3D"">
1965</=option>
 <option value=3D"1966" style=3D"">
1966</option>
 <option value=3D"196=7" style=3D"">
1967</option>
 <option value=3D"1968" style=3D"">
1968</option>
 <=option value=3D"1969" style=3D"">
1969</option>
 <option value=3D"1970" style=3D="">
1970</option>
 <option value=3D"1971" style=3D"">
1971</option>
 <option val=ue=3D"1972" style=3D"">
1972</option>
 <option value=3D"1973" style=3D"">
1973<=/option>
 <option value=3D"1974" style=3D"">
1974</option>
 <option value=3D"19=75" style=3D"">
1975</option>
 <option value=3D"1976" style=3D"">
1976</option>
= <option value=3D"1977" style=3D"">
1977</option>
 <option value=3D"1978" styl=e=3D"">
1978</option>
 <option value=3D"1979" style=3D"">
1979</option>
 <option= value=3D"1980" style=3D"">
1980</option>
 <option value=3D"1981" style=3D"">
1=981</option>
 <option value=3D"1982" style=3D"">
1982</option>
 <option value=3D="1983" style=3D"">
1983</option>
 <option value=3D"1984" style=3D"">
1984</opti=on>
 <option value=3D"1985" style=3D"">
1985</option>
 <option value=3D"1986" s=tyle=3D"">
1986</option>
 <option value=3D"1987" style=3D"">
1987</option>
 <opt=ion value=3D"1988" style=3D"">
1988</option>
 <option value=3D"1989" style=3D"=">
1989</option>
 <option value=3D"1990" style=3D"">
1990</option>
 <option valu=e=3D"1991" style=3D"">
1991</option>
 <option value=3D"1992" style=3D"">
1992</=option>
 <option value=3D"1993" style=3D"">
1993</option>
 <option value=3D"199=4" style=3D"">
1994</option>
 <option value=3D"1995" style=3D"">
1995</option>
 <=option value=3D"1996" style=3D"">
1996</option>
 <option value=3D"1997" style=3D="">
1997</option>
 <option value=3D"1998" style=3D"">
1998</option>
 <option val=ue=3D"1999" style=3D"">
1999</option>
 <option value=3D"2000" style=3D"">
2000<=/option>
 <option value=3D"2001" style=3D"">
2001</option>
 <option value=3D"20=02" style=3D"">
2002</option>
 <option value=3D"2003" style=3D"">
2003</option>
= <option value=3D"2004" style=3D"">
2004</option>
 <option value=3D"2005" styl=e=3D"">
2005</option>
 <option value=3D"2006" style=3D"">
2006</option>
 <option= value=3D"2007" style=3D"">
2007</option>
 <option value=3D"2008" style=3D"">
2=008</option>
 <option value=3D"2009" style=3D"">
2009</option>
 <option value=3D="2010" style=3D"">
2010</option>
 <option value=3D"2011" style=3D"">
2011</opti=on>
 <option value=3D"2012" style=3D"">
2012</option>
 <option value=3D"2013" s=tyle=3D"">
2013</option>
 <option value=3D"2014" style=3D"">
2014</option>
 <opt=ion value=3D"2015" style=3D"">
2015</option>
 <option value=3D"2016" style=3D"=">
2016</option>
 <option value=3D"2017" style=3D"">
2017</option>
 <option valu=e=3D"2018" style=3D"">
2018</option>
 <option value=3D"2019" selected=3D"" sty=le=3D"">
2019</option>
 <option value=3D"2020" style=3D"">
2020</option>
 <optio=n value=3D"2021" style=3D"">
2021</option>
 <option value=3D"2022" style=3D"">
=2022</option>
 <option value=3D"2023" style=3D"">
2023</option>
 <option value=3D="2024" style=3D"">
2024</option>
 <option value=3D"2025" style=3D"">
2025</opti=on>
 <option value=3D"2026" style=3D"">
2026</option>
 <option value=3D"2027" s=tyle=3D"">
2027</option>
 <option value=3D"2028" style=3D"">
2028</option>
 <opt=ion value=3D"2029" style=3D"">
2029</option>
 <option value=3D"2030" style=3D"=">
2030</option>
 <option value=3D"2031" style=3D"">
2031</option>
 <option valu=e=3D"2032" style=3D"">
2032</option>
 <option value=3D"2033" style=3D"">
2033</=option>
 <option value=3D"2034" style=3D"">
2034</option>
 <option value=3D"203=5" style=3D"">
2035</option>
 <option value=3D"2036" style=3D"">
2036</option>
 <=option value=3D"2037" style=3D"">
2037</option>
 <option value=3D"2038" style=3D="">
2038</option>
 <option value=3D"2039" style=3D"">
2039</option>
 <option val=ue=3D"2040" style=3D"">
2040</option>
 <option value=3D"2041" style=3D"">
2041<=/option>
 <option value=3D"2042" style=3D"">
2042</option>
 <option value=3D"20=43" style=3D"">
2043</option>
 <option value=3D"2044" style=3D"">
2044</option>
= <option value=3D"2045" style=3D"">
2045</option>
 <option value=3D"2046" styl=e=3D"">
2046</option>
 <option value=3D"2047" style=3D"">
2047</option>
 <option= value=3D"2048" style=3D"">
2048</option>
 <option value=3D"2049" style=3D"">
2=049</option>
 <option value=3D"2050" style=3D"">
2050</option>
 <option value=3D="2051" style=3D"">
2051</option>
 <option value=3D"2052" style=3D"">
2052</opti=on>
 <option value=3D"2053" style=3D"">
2053</option>
 <option value=3D"2054" s=tyle=3D"">
2054</option>
 <option value=3D"2055" style=3D"">
2055</option>
 <opt=ion value=3D"2056" style=3D"">
2056</option>
 <option value=3D"2057" style=3D"=">
2057</option>
 <option value=3D"2058" style=3D"">
2058</option>
 <option valu=e=3D"2059" style=3D"">
2059</option>
 <option value=3D"2060" style=3D"">
2060</=option>
 <option value=3D"2061" style=3D"">
2061</option>
 <option value=3D"206=2" style=3D"">
2062</option>
 <option value=3D"2063" style=3D"">
2063</option>
 <=option value=3D"2064" style=3D"">
2064</option>
 <option value=3D"2065" style=3D="">
2065</option>
 <option value=3D"2066" style=3D"">
2066</option>
 <option val=ue=3D"2067" style=3D"">
2067</option>
 <option value=3D"2068" style=3D"">
2068<=/option>
 <option value=3D"2069" style=3D"">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-time" style=3D"margin=:12px 0;font:inherit;">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1=.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_206244955" style=3D"">
<div cla=ss=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;m=argin-bottom:.83em;">
Hora de la Atenci=C3=B3n<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
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<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
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<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
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6</label>
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8</l=abel>
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9</label>
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10</label>
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<input type=3D"radio" name=3D"entry.1421689035" disabled=3D"" va=lue=3D"2" id=3D"group_1421689035_3" role=3D"radio" class=3D"ss-q-radio" aria=-label=3D"2" style=3D"">
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<div class=3D"ss-scale=row-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entry.1421689035" di=sabled=3D"" value=3D"10" id=3D"group_1421689035_11" role=3D"radio" class=3D"=ss-q-radio" aria-label=3D"10" style=3D"">
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</div>
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<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
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<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
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<tr aria-hidden=3D"true" style=3D"">
<td class=3D"ss-sc=alenumbers" style=3D"text-align:center;">
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<label class=3D="ss-scalenumber" for=3D"group_1244707512_4" style=3D"display:block;padding:0=.5em 0 .5em;">
3</label>
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<label class=3D"ss-scalenumber" for=3D"group_1244707512_5" style==3D"display:block;padding:0.5em 0 .5em;">
4</label>
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<label class=3D"ss-scalenumber" for=3D="group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em;">
5</label>
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6</label>
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<label class=3D"ss-scalenumber" for=3D"group_1244707512_8" s=tyle=3D"display:block;padding:0.5em 0 .5em;">
7</label>
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<label class=3D"ss-scalenumber" f=or=3D"group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em;">
8</l=abel>
</td>
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<label= class=3D"ss-scalenumber" for=3D"group_1244707512_10" style=3D"display:block=;padding:0.5em 0 .5em;">
9</label>
</td>
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<label class=3D"ss-scalenumber" for=3D"group_1244707512=_11" style=3D"display:block;padding:0.5em 0 .5em;">
10</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center;">
</td>
</tr>
<tr role=3D"radiogroup" aria-label=3D"Escala Dolor EVA M=C3=A1ximo  Seleccio=na un valor en el rango de 0 a 10." style=3D"">
<td class=3D"ss-scalerow ss-l=eftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;bord=er-left:0;border-right:0;padding:.5em .25em;padding-left:0;">
<div aria-hidde=n=3D"true" class=3D"aria-todo" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow" style=3D"text-align:center;color:#666;border:1px s=olid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;">
<div class=3D="ss-scalerow-fieldcell" style=3D"">
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</div>
</td>
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</div>
</td>
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<div class=3D"ss-scalerow-fieldcell" style=3D"">
=<input type=3D"radio" name=3D"entry.1244707512" disabled=3D"" value=3D"2" id==3D"group_1244707512_3" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"2"= style=3D"">
</div>
</td>
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<div class=3D"ss-scalerow-fieldcell" style=3D"">
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</div=>
</td>
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<div c=lass=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entr=y.1244707512" disabled=3D"" value=3D"4" id=3D"group_1244707512_5" role=3D"ra=dio" class=3D"ss-q-radio" aria-label=3D"4" style=3D"">
</div>
</td>
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<div class=3D"ss-scalerow=-fieldcell" style=3D"">
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</div>
</td>
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<div class=3D"ss-scalerow-fie=ldcell" style=3D"">
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</div>
</td>
 <td class=3D"ss-scalerow" style=3D"=text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-r=ight:0;padding:.5em .25em;">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
=<input type=3D"radio" name=3D"entry.1244707512" disabled=3D"" value=3D"7" id==3D"group_1244707512_8" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"7"= style=3D"">
</div>
</td>
 <td class=3D"ss-scalerow" style=3D"text-align:center=;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5=em .25em;">
<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D"ra=dio" name=3D"entry.1244707512" disabled=3D"" value=3D"8" id=3D"group_1244707=512_9" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"8" style=3D"">
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<input type=3D"radio" name=3D"entr=y.1244707512" disabled=3D"" value=3D"9" id=3D"group_1244707512_10" role=3D"r=adio" class=3D"ss-q-radio" aria-label=3D"9" style=3D"">
</div>
</td>
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<div class=3D"ss-scale=row-fieldcell" style=3D"">
<input type=3D"radio" name=3D"entry.1244707512" di=sabled=3D"" value=3D"10" id=3D"group_1244707512_11" role=3D"radio" class=3D"=ss-q-radio" aria-label=3D"10" style=3D"">
</div>
</td>
<td class=3D"ss-scalerow ss-rightlabel" aria-hidden=3D"true" style=3D"text-a=lign:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;p=adding:.5em .25em;padding-right:0;">
</td>
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</tbody>
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<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertica=l-align:middle;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_2000523015" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Escala Dolor EVA M=C3=ADnimo</div>
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</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center;">
<label class=3D"s=s-scalenumber" for=3D"group_853118630_1" style=3D"display:block;padding:0.5e=m 0 .5em;">
0</label>
</td>
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<label class=3D"ss-scalenumber" for=3D"group_853118630_2" style=3D"=display:block;padding:0.5em 0 .5em;">
1</label>
</td>
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2</label>
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3</label>
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<label class=3D"ss-scalenumber" for=3D"group_853118630_5" style=3D="display:block;padding:0.5em 0 .5em;">
4</label>
</td>
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5</label>
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<label class=3D="ss-scalenumber" for=3D"group_853118630_7" style=3D"display:block;padding:0.=5em 0 .5em;">
6</label>
</td>
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7</label>
</td>
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8</label>
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<label class=3D="ss-scalenumber" for=3D"group_853118630_10" style=3D"display:block;padding:0=.5em 0 .5em;">
9</label>
</td>
 <td class=3D"ss-scalenumbers" style=3D"text-ali=gn:center;">
<label class=3D"ss-scalenumber" for=3D"group_853118630_11" style==3D"display:block;padding:0.5em 0 .5em;">
10</label>
</td>
<td class=3D"ss-scalenumbers" style=3D"text-align:center;">
</td>
</tr>
<tr role=3D"radiogroup" aria-label=3D"Escala Dolor EVA M=C3=ADnimo  Seleccio=na un valor en el rango de 0 a 10." style=3D"">
<td class=3D"ss-scalerow ss-l=eftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;bord=er-left:0;border-right:0;padding:.5em .25em;padding-left:0;">
<div aria-hidde=n=3D"true" class=3D"aria-todo" style=3D"">
</div>
</td>
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<div class=3D"ss-scalerow-fieldcell" sty=le=3D"">
<input type=3D"radio" name=3D"entry.853118630" disabled=3D"" value=3D="2" id=3D"group_853118630_3" role=3D"radio" class=3D"ss-q-radio" aria-label=3D="2" style=3D"">
</div>
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<div class=3D"ss-scalerow-fieldcell" style=3D"">
<input type=3D="radio" name=3D"entry.853118630" disabled=3D"" value=3D"3" id=3D"group_85311=8630_4" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"3" style=3D"">
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<input type=3D"radio" name=3D"entry.=853118630" disabled=3D"" value=3D"8" id=3D"group_853118630_9" role=3D"radio"= class=3D"ss-q-radio" aria-label=3D"8" style=3D"">
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<input type=3D"radio" name=3D"entry.853118630" disabled==3D"" value=3D"9" id=3D"group_853118630_10" role=3D"radio" class=3D"ss-q-rad=io" aria-label=3D"9" style=3D"">
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</div>
</td>
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</td>
</tr>
</tbody>
</table>
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PACIENTE EN REGULAR ESTADO GENERAL PASANDO POR UN RESFRIO BAS=TANTE FUERTE POR LO CUAL QMT QUE SE REALIZARA EL MIERCOLES 15 QUEDA SUSPENDI=A HASTA NUEVA PROGRAMACION Y CESE DE LOS SINTOMAS DE LA PACIENTE.REFIERE QUE AH MANIFESTADO MOLESTIAS EN ESTAS ULTIMAS 4 SEMANAS SIN QMT, CON= MUCHO DOLOR QUE PASAN CON PARCHES DE FENTANILO 1/2 PARCHE.CONSTANTEMENTE DE VIAJE ENTRE SANTIAGO Y OLMUE, POR LO CUAL SE SIENTE CANSAD=A Y SIN ANIMOS.AUN SIN RESPUESTA DEL UROLOGO ONCOLOGO , MEDICAMENTOS QUE RECETEAN ESTAN DES=CONTINUADOS Y NO HAN TENIDO TIEMPO PARA UNA NUEVA CONSULTA POR LO CUAL SIGUE= CON LA INCONTINENCIA=20ALIMENTACIO NORMALDEPOS HACE TRES DIAS SIN DEPOS</div>
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PACIENTE CON HEMODINAMIA ESTABLE TENDIENDO AL AHIPERTENSION 1=45/77 NORMOCARDICA 89X AFEBRIL SATURACION OPTIMASIN APREMIO VENTILARIOPIEL SANA SIN LESIONES AREA DE PORTH A CATH SANO SIN ENROJECIMIENTO=20ABDIEXTREMIDADES BIEN PERFUNDIDAS=20DIURESIS INTERMITENTS=20DEPOS NORMALES DIARIAS=20</div>
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CA OVARIO ETAPA IV </div>
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<label class=3D"ss-q-item-label" for=3D"entry_1255665248" style=3D"">
<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Plan de Tratamiento e Indicaciones<label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)"= style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c4=3b1d;">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
- MANEJO DEL DOLOR=20- APOYO KINESICO Y NUTRICIONAL SEMANAL , NO SE HA LOGRADO CONGENIAR HORARIOS= CON PROFESIONALES YA QUE PACIENTE CONSTANTEMENTE SE ENCUENTRA VIAJANDO </di=v>
</div>
</div>
</div>
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<div cl=ass=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;=margin-bottom:.83em;">
Medicamentos Indicados</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
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- 1/2 PARCHE DE FENTANILO CAMBIO CADA 72 HORAS- TRAMADOL GOTAS EN SOS DE 5 A 10 GOTAS CASA 12 HORAS O SOS </div>
</div>
</div>
</div>
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<div dir=3D"auto" class=3D"ss-item  ss-date" style=3D"margin:12px 0;">
<div c=lass=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;ma=rgin-left:0;margin-top:0;max-width:100%;">
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<div cl=ass=3D"ss-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"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
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<div class=3D"ss-q-date" role=3D"group" aria-label=3D"Fecha aproximada del P=r=C3=B3ximo Control con usted  " style=3D"">
<div class=3D"ss-datetime-box go=og-inline-block" role=3D"group" style=3D"border:1px solid #dcdcdc;margin-rig=ht:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px=;position:relative;display:inline-block;">
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Mes</option>
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enero</option>
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febrero</option>
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marzo</option>
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abril</option>
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mayo</option>
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junio</option>
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julio</option>
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agosto</opti=on>
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septiembre</option>
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octubre</option>
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noviembre</option=>
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diciembre</option>
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D=C3=ADa</option>
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1</option>
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3</option>
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4</option>
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6</option>
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7</option>
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11</o=ption>
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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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19</option>
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20</option>
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21</opti=on>
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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</o=ption>
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29</option>
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30</option>
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31</option>
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A=C3=B1=o</option>
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1896</option>
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1897</option>
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1898</option>
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1899</option>
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190=0</option>
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1901</option>
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1902</option>
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1903</optio=n>
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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</o=ption>
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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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1=927</option>
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1928</option>
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1929</option>
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1930</opti=on>
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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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1=954</option>
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1955</option>
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1956</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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1972</option>
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1974</option>
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1975</option>
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1976</option>
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1978</option>
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1979</option>
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1980</option>
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1=981</option>
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1982</option>
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1983</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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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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2=008</option>
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2009</option>
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2010</option>
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2011</opti=on>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
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2019</option>
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2020</option>
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2021</option>
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=2022</option>
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2023</option>
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2024</option>
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2025</opti=on>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
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2032</option>
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2033</=option>
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2034</option>
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2035</option>
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2036</option>
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2037</option>
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2038</option>
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2039</option>
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2040</option>
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2041<=/option>
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2042</option>
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2043</option>
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2044</option>
= <option value=3D"2045" style=3D"">
2045</option>
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2046</option>
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2047</option>
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2048</option>
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2=049</option>
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2050</option>
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2051</option>
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2052</opti=on>
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2053</option>
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2054</option>
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2055</option>
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2056</option>
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2057</option>
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2058</option>
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2059</option>
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2060</=option>
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2061</option>
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2062</option>
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2063</option>
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2064</option>
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2065</option>
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2066</option>
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2067</option>
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2068<=/option>
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2069</option>
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<br>
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<div dir=3D"auto" class=3D"ss-item  ss-text" style=3D"margin:12px 0;">
<div c=lass=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;ma=rgin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_74766472" style=3D"">
<div clas=s=3D"ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;ma=rgin-bottom:.83em;">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-wid=th:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#5454=54;width:70%;">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D="">
<div dir=3D"auto" class=3D"ss-item  ss-checkbox" style=3D"margin:12px 0;">
<d=iv class=3D"ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middl=e;margin-left:0;margin-top:0;max-width:100%;">
<label class=3D"ss-q-item-label" for=3D"entry_1219705969" style=3D"">
<div cl=ass=3D"ss-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"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:blo=ck;margin:.1em 0 .25em 0;color:#666;">
S=C3=B3lo llene esta secci=C3=B3n si e=s m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
</label=>
<ul class=3D"ss-choices" role=3D"group" aria-label=3D"Derivaci=C3=B3n a otro= Prestador Domiciliario S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y= solicita la visita de otro prestador del equipo " style=3D"list-style:none;=padding:0;margin:.5em 0 0;">
<li class=3D"ss-choice-item" style=3D"margin:0;l=ine-height:1.3em;padding-bottom:.5em;">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"pos=ition:relative;display:inline-block;">
<input type=3D"checkbox" name=3D"entry=.503039759" disabled=3D"" value=3D"ENFERMERA" id=3D"group_503039759_1" role=3D="checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
ENFERMERA</span>
</label>
</li>
 <li class=3D"ss-choice-item" style=3D"margin:0;line-height:1.3=em;padding-bottom:.5em;">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"pos=ition:relative;display:inline-block;">
<input type=3D"checkbox" name=3D"entry=.503039759" disabled=3D"" value=3D"TENS" id=3D"group_503039759_2" role=3D"ch=eckbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
TENS</span>
</label>
</li>
 <li class=3D"ss-choice-item" style=3D"margin:0;line-height:1.3=em;padding-bottom:.5em;">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"pos=ition:relative;display:inline-block;">
<input type=3D"checkbox" name=3D"entry=.503039759" disabled=3D"" value=3D"NUTRICIONISTA" id=3D"group_503039759_3" r=ole=3D"checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
NUTRICIONISTA</span>
</label>
</li>
 <li class=3D"ss-choice-item" style=3D"margin:0;line-height:1.3=em;padding-bottom:.5em;">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"pos=ition:relative;display:inline-block;">
<input type=3D"checkbox" name=3D"entry=.503039759" disabled=3D"" value=3D"KINESIOLOGO" id=3D"group_503039759_4" rol=e=3D"checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
KINESIOLOGO</span>
</label>
</li>
 <li class=3D"ss-choice-item" style=3D"margin:0;line-height:1.3=em;padding-bottom:.5em;">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"pos=ition:relative;display:inline-block;">
<input type=3D"checkbox" name=3D"entry=.503039759" disabled=3D"" value=3D"PSICOLOGO" id=3D"group_503039759_5" role=3D="checkbox" class=3D"ss-q-checkbox" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style=3D="margin:12px 0;max-width:100%;position:relative;">
<div class=3D"ss-form-entr=y" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-t=op:0;max-width:100%;">
<h2 class=3D"ss-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"ss-image" title=3D"" src=3D"=https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9=VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width: 78px;outline:none;" alt=3D="Imagen sin t=C3=ADtulo">
</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%" role=3D"presentation">
<tbod=y>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.c=om/forms?usp=3Dmail_form_link" style=3D"color: #424242; font-size: 13px;">
Cr=ear tu propio Formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
=</blockquote>
</body>
</html>
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