<div dir=3D"auto">
</div>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class=3D"gmail_attr">
---------- Forwarded message ---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Formularios de Google</strong>
 <span dir=3D"ltr">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: mar., 11 jun. 2019 23:21<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:eveortegaa@gmail.com">
eveortegaa@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Formularios de Google" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por rellenar <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target=3D"_blank" rel=3D"noreferrer">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_5906683466233779093ss-form-container">
<div class=3D"m_5906683466233779093ss-form-heading">
<h1 class=3D"m_5906683466233779093ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_5906683466233779093ss-form-desc m_5906683466233779093ss-no-ignore-whitespace" style=3D"font:inherit;width:99%;margin:0 0 1em;white-space:pre-wrap;word-wrap:break-word">
Este es el sistema de registro de atenciones domiciliarias de Oncovida.   Debe ser llenado por el prestador individual, y debe realizarse un registro por cada visita domiciliaria.   Si usted no es prestador de Oncovida por favor no llene este formulario.   A continuaci=C3=B3n indique su correo electr=C3=B3nico.</div>
</div>
<div class=3D"m_5906683466233779093ss-form">
<form method=3D"GET" id=3D"m_5906683466233779093ss-form" target=3D"_blank">
<br>
<div class=3D"m_5906683466233779093ss-form-question m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-item-required m_5906683466233779093ss-text" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093emailAddress">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Direcci=C3==B3n de correo electr=C3=B3nico<label for=3D"m_5906683466233779093emailAddress">
</label>
<span class=3D"m_5906683466233779093ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_5906683466233779093ss-q-text m_5906683466233779093ss-printable-text-line" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
<a href=3D"mailto:eveortegaa@gmail.com" target=3D"_blank" rel=3D"noreferrer">
eveortegaa@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_5906683466233779093ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_5906683466233779093ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_5906683466233779093ss-page-description m_5906683466233779093ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
Aqu=C3=AD debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093ss-form-question m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-item-required m_5906683466233779093ss-text" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_579114469">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_5906683466233779093itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5906683466233779093ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5906683466233779093ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Evelyn Ortega</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093ss-form-question m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-item-required m_5906683466233779093ss-text" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_1276273985">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_5906683466233779093itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5906683466233779093ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_5906683466233779093ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
16273226-9</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093ss-form-question m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-item-required m_5906683466233779093ss-select" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_133691676">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_5906683466233779093itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5906683466233779093ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
Si asisten m=C3=A1s de 1 prestador simult=C3=A1neamente, cada uno debe hacer un registro independiente</div>
</label>
<select name=3D"entry.133691676" disabled id=3D"m_5906683466233779093entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled selected>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_5906683466233779093ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_5906683466233779093ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_5906683466233779093ss-page-description m_5906683466233779093ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_5906683466233779093ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_5906683466233779093ss-section-description m_5906683466233779093ss-no-ignore-whitespace" style=3D"margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093ss-form-question m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-item-required m_5906683466233779093ss-text" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_823811303">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_5906683466233779093itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5906683466233779093ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"m_5906683466233779093ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
5762589-9</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093ss-form-question m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-item-required m_5906683466233779093ss-text" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_1959365839">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente<label for=3D"m_5906683466233779093itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5906683466233779093ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5906683466233779093ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Elena Saez</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093ss-form-question m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-item-required m_5906683466233779093ss-select" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_545002227">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_5906683466233779093itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5906683466233779093ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.545002227" disabled id=3D"m_5906683466233779093entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled>
COLMENA</option>
 <option value=3D"CONSALUD" disabled>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled selected>
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled>
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled>
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093ss-form-question m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-item-required m_5906683466233779093ss-text" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_1900161356">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_5906683466233779093itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5906683466233779093ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5906683466233779093ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Talca</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093ss-form-question m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-item-required m_5906683466233779093ss-text" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_1298871758">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_5906683466233779093itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5906683466233779093ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5906683466233779093ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
Talca</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_5906683466233779093ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_5906683466233779093ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_5906683466233779093ss-page-description m_5906683466233779093ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos de la atenci==C3=B3n domiciliaria</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093ss-form-question m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-item-required m_5906683466233779093ss-radio" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_2073233714">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_5906683466233779093itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5906683466233779093ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_5906683466233779093ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_5906683466233779093ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
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<input type==3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_5906683466233779093group_1222378237_1" class=3D"m_5906683466233779093ss-q-radio">
</span>
<span class=3D"m_5906683466233779093ss-choice-label">
Domicilio</span>
</label>
</li>
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<label>
<span class=3D"m_5906683466233779093ss-choice-item-control m_5906683466233779093goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_5906683466233779093group_1222378237_2" class=3D"m_5906683466233779093ss-q-radio">
</span>
<span class=3D"m_5906683466233779093ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093ss-form-question m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-item-required m_5906683466233779093ss-date" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_1705849412">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha de la Atenci=C3=B3n<label for=3D"m_5906683466233779093itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5906683466233779093ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5906683466233779093ss-q-date">
<div class=3D"m_5906683466233779093ss-datetime-box m_5906683466233779093goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
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D=C3=ADa</option>
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1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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Mes</option>
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enero</option>
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febrero</option>
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marzo</option>
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abril</option>
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mayo</option>
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junio</option>
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julio</option>
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agosto</option>
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septiembre</option>
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octubre</option>
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noviembre</option>
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diciembre</option>
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=20<select name=3D"entry.1705849412_year" disabled id=3D"m_5906683466233779093entry.1705849412_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
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2019</option>
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2020</option>
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2021</option>
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2022</option>
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2023</option>
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2024</option>
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2025</option>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
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2032</option>
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2033</option>
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2034</option>
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2035</option>
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2036</option>
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2037</option>
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2038</option>
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2039</option>
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2040</option>
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2041</option>
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2042</option>
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2043</option>
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2044</option>
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2045</option>
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2046</option>
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2047</option>
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2048</option>
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2049</option>
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2050</option>
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2051</option>
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2052</option>
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2053</option>
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2054</option>
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2055</option>
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2056</option>
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2057</option>
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2058</option>
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2059</option>
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2060</option>
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2061</option>
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2062</option>
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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>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093ss-form-question m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-item-required m_5906683466233779093ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_206244955">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Hora de la Atenci=C3=B3n<label for=3D"m_5906683466233779093itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5906683466233779093ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5906683466233779093ss-q-time">
<div class=3D"m_5906683466233779093ss-datetime-box m_5906683466233779093goog-inline-block" dir=3D"ltr" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
<select name=3D"entry.206244955_hour" disabled id=3D"m_5906683466233779093entry.206244955_hour">
<option value=3D"">
h</option>
<option value=3D"00">
00</option>
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01</option>
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02</option>
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03</option>
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04</option>
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05</option>
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06</option>
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07</option>
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08</option>
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09</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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:<select name=3D"entry.206244955_minute" disabled id=3D"m_5906683466233779093entry.206244955_minute">
<option value=3D"">
min</option>
<option value=3D"00">
00</option>
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01</option>
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02</option>
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03</option>
 <option value=3D"04">
04</option>
 <option value=3D"05">
05</option>
 <option value=3D"06">
06</option>
 <option value=3D"07">
07</option>
 <option value=3D"08">
08</option>
 <option value=3D"09">
09</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value==3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31">
31</option>
 <option value=3D"32">
32</option>
 <option value=3D"33">
33</option>
 <option value=3D"34">
34</option>
 <option value=3D"35">
35</option>
 <option value=3D"36">
36</option>
 <option value=3D"37">
37</option>
 <option value=3D"38">
38</option>
 <option value=3D"39">
39</option>
 <option value=3D"40">
40</option>
 <option value=3D"41">
41</option>
 <option value=3D"42">
42</option>
 <option value=3D"43">
43</option>
 <option value=3D"44">
44</option>
 <option value=3D"45" selected>
45</option>
 <option value=3D"46">
46</option>
 <option value=3D"47">
47</option>
 <option value=3D"48">
48</option>
 <option value=3D"49">
49</option>
 <option value=3D"50">
50</option>
 <option value=3D"51">
51</option>
 <option value=3D"52">
52</option>
 <option value=3D"53">
53</option>
 <option value=3D"54">
54</option>
 <option value=3D"55">
55</option>
 <option value=3D"56">
56</option>
 <option value=3D"57">
57</option>
 <option value=3D"58">
58</option>
 <option value=3D"59">
59</option>
</select>
<div class=3D"m_5906683466233779093ss-datetime-box-spacer m_5906683466233779093goog-inline-block" style=3D"height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093ss-form-question m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-item-required m_5906683466233779093ss-select" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_1747608258">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_5906683466233779093itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5906683466233779093ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.1747608258" disabled id=3D"m_5906683466233779093entry_1747608258">
<option value=3D"">
</option>
<option value=3D"0" disabled selected>
0</option>
 <option value=3D"1" disabled>
1</option>
 <option value=3D"2" disabled>
2</option>
 <option value=3D"3" disabled>
3</option>
 <option value=3D"4" disabled>
4</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093ss-form-question m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_1716090865">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_5906683466233779093entry_1421689035">
<tr>
<td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1421689035_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_5906683466233779093ss-scalerow m_5906683466233779093ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_5906683466233779093aria-todo">
</div>
</td>
<td class=3D"m_5906683466233779093ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
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</div>
</td>
 <td class=3D"m_5906683466233779093ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_5906683466233779093ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value==3D"1" id=3D"m_5906683466233779093group_1421689035_2" class=3D"m_5906683466233779093ss-q-radio">
</div>
</td>
 <td class=3D"m_5906683466233779093ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_5906683466233779093ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"2" id=3D"m_5906683466233779093group_1421689035_3" class=3D"m_5906683466233779093ss-q-radio">
</div>
</td>
 <td class=3D"m_5906683466233779093ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_5906683466233779093ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3" id=3D"m_5906683466233779093group_1421689035_4" class=3D"m_5906683466233779093ss-q-radio">
</div>
</td>
 <td class=3D"m_5906683466233779093ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_5906683466233779093ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_5906683466233779093group_1421689035_5" class=3D"m_5906683466233779093ss-q-radio">
</div>
</td>
 <td class=3D"m_5906683466233779093ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_5906683466233779093ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_5906683466233779093group_1421689035_6" class=3D"m_5906683466233779093ss-q-radio">
</div>
</td>
 <td class=3D"m_5906683466233779093ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_5906683466233779093ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_5906683466233779093group_1421689035_7" class=3D"m_5906683466233779093ss-q-radio">
</div>
</td>
 <td class=3D"m_5906683466233779093ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_5906683466233779093ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"7" id=3D"m_5906683466233779093group_1421689035_8" class=3D"m_5906683466233779093ss-q-radio">
</div>
</td>
 <td class=3D"m_5906683466233779093ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_5906683466233779093ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_5906683466233779093group_1421689035_9" class=3D"m_5906683466233779093ss-q-radio">
</div>
</td>
 <td class=3D"m_5906683466233779093ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_5906683466233779093ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_5906683466233779093group_1421689035_10" class=3D"m_5906683466233779093ss-q-radio">
</div>
</td>
 <td class=3D"m_5906683466233779093ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class==3D"m_5906683466233779093ss-scalerow-fieldcell">
<input type=3D"radio" name==3D"entry.1421689035" disabled value=3D"10" id=3D"m_5906683466233779093group_1421689035_11" class=3D"m_5906683466233779093ss-q-radio">
</div>
</td>
<td class=3D"m_5906683466233779093ss-scalerow m_5906683466233779093ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093ss-form-question m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_2064050596">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=A1ximo</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0" id=3D"m_5906683466233779093entry_1244707512">
<tr>
<td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_5906683466233779093ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_5906683466233779093ss-scalerow m_5906683466233779093ss-leftlabel" style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div class=3D"m_5906683466233779093aria-todo">
</div>
</td>
<td class=3D"m_5906683466233779093ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_5906683466233779093ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"0" id=3D"m_5906683466233779093group_1244707512_1" class=3D"m_5906683466233779093ss-q-radio">
</div>
</td>
 <td class=3D"m_5906683466233779093ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div class=3D"m_5906683466233779093ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"1" id=3D"m_5906683466233779093group_1244707512_2" class=3D"m_5906683466233779093ss-q-radio">
</div>
</td>
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Escala Dolor EVA M=C3=ADnimo</div>
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0</label>
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<label class=3D"m_5906683466233779093ss-scalenumber" for==3D"m_5906683466233779093group_853118630_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
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2</label>
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3</label>
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4</label>
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5</label>
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6</label>
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7</label>
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8</label>
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<label class=3D"m_5906683466233779093ss-scalenumber" for=3D"m_5906683466233779093group_853118630_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
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10</label>
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</td>
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Anamnesis/Evoluci=C3=B3n<label for=3D"m_5906683466233779093itemView.getDomIdToLabel()">
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Paciente residia en la ciudad de Santiago, es trasladada a la ciudad de Talca, con diagnostico de Ca Pulmonar, de 72 a=C3=B1os, vive con su hija Pamela, yerno, nietos, duela de casa, no presenta antecedentes morbidos, ni alergicos, si presenta antecedentes quirurgicos, refiere que fue operada de los &quot; ojos&quot;, &quot;varices&quot;, &quot;brazo&quot;, &quot;mamas&quot; (quistes) y implantes dentales. Refiere que en su familia presenta antecedentes de Ca, su padre Ca de estomago, y su medio hermano Ca prostata.Paciente refiere  que el 29 de abril se realizo una muestra de pulmon izquierdo, biopsia percutanea bajo TAC, informando tejido pulmonar infiltrado por Carcinoma adenoescamoso bien diferenciado. Se complemento con estudio inmunohistoquimico obteniendose reaccion positiva intensa y difusa para TTF-1 en el componente de adenocarcinoma (acinar 70%, solido 20%, papilar 10%) y reaccion negativaen el componente escamoso, este ultimo componente de menos representacion.El dia 15 de mayo 2019 ingresa a primer ciclo QTX con Carbo-Alemta+ Avastin, tolerando muy bien la QTX, no presenta nauseas ni vomitos, transito digestivo normal, SV en rangos normales, sin fiebre ni otro sintoma de infecciones, no refiere dolor, procedimiento sin problemas, ex fisico sin cambios.Tratamiento: Dexametasona 4 mg 1ml, domperidona 10 mg oral, enoxaparina 40 mg (clexane), esomeprazol 40 mg(nexium), nisetron 1 mg, omeprazol 40 mg, paracetamol 1 gr/100ml.Indicaciones al alta: Regimen liviano, reposo relativo por dos o 3 dias y luego normal.Al momento de la visita, paciente deambula sin dificultad, no presenta dolor, pero si refiere que ha presentado dolor de estomago EVA 8/10, junto con &quot;gases&quot;, refiere buen apetito, sin dificultad para dormir, diuresis (+) en ba=C3=B1o, deposiciones (-) estre=C3=B1imiento, esta tomando ciruelax diario, presenta tos, mareos.</div>
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Examen F=C3=ADsico<label for=3D"m_5906683466233779093itemView.getDomIdToLabel()">
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Al control de signos vitales:P/A: 135/86FC: 99T: 35.2Sat: 84Piel: indemne, tibia al tactoCabeza: normocraneo, cabello oscuro.Abdomen: blando, depresible no doloroso a la palpacion.Ext sup: movilesExt inf: moviles, edema (-)</div>
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*</span>
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Ca pulmon</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093ss-form-question m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-item-required m_5906683466233779093ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_1255665248">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_5906683466233779093itemView.getDomIdToLabel()">
</label>
<span class=3D"m_5906683466233779093ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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1.- Control 7 dias2.- Refuerzo farmacologico.</div>
</div>
</div>
</div>
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<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-paragraph-text" style=3D"margin:12px 0">
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<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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1.- Esomeprazol 40 mg2.- Paracetamol3.- Acido Folico4.- Domperidona5.-Bromuro de Ipatropio</div>
</div>
</div>
</div>
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<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-date" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_2063615873">
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Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
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<div class=3D"m_5906683466233779093ss-q-date">
<div class=3D"m_5906683466233779093ss-datetime-box m_5906683466233779093goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
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<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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Mes</option>
<option value=3D"1">
enero</option>
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febrero</option>
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marzo</option>
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abril</option>
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mayo</option>
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junio</option>
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julio</option>
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agosto</option>
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septiembre</option>
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octubre</option>
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noviembre</option>
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diciembre</option>
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A=C3=B1o</option>
<option value=3D"1896">
1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
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2019</option>
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2020</option>
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2021</option>
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2022</option>
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2023</option>
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2024</option>
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2025</option>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
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2032</option>
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2033</option>
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2034</option>
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2035</option>
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2036</option>
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2037</option>
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2038</option>
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2039</option>
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2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
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2049</option>
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2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
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2053</option>
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2054</option>
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2055</option>
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2056</option>
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2057</option>
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2058</option>
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2059</option>
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2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
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2067</option>
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2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
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<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-text" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_74766472">
<div class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_5906683466233779093ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
</div>
</div>
</div>
</div>
<br>
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<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_5906683466233779093ss-q-item-label" for=3D"m_5906683466233779093entry_1219705969">
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Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_5906683466233779093ss-q-help m_5906683466233779093ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
</label>
<ul class=3D"m_5906683466233779093ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
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<label>
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<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"ENFERMERA" id=3D"m_5906683466233779093group_503039759_1" class=3D"m_5906683466233779093ss-q-checkbox">
</span>
<span class=3D"m_5906683466233779093ss-choice-label">
ENFERMERA</span>
</label>
</li>
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<label>
<span class=3D"m_5906683466233779093ss-choice-item-control m_5906683466233779093goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_5906683466233779093group_503039759_2" class=3D"m_5906683466233779093ss-q-checkbox">
</span>
<span class=3D"m_5906683466233779093ss-choice-label">
TENS</span>
</label>
</li>
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<label>
<span class=3D"m_5906683466233779093ss-choice-item-control m_5906683466233779093goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id==3D"m_5906683466233779093group_503039759_3" class=3D"m_5906683466233779093ss-q-checkbox">
</span>
<span class=3D"m_5906683466233779093ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
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<label>
<span class=3D"m_5906683466233779093ss-choice-item-control m_5906683466233779093goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"KINESIOLOGO" id=3D"m_5906683466233779093group_503039759_4" class=3D"m_5906683466233779093ss-q-checkbox">
</span>
<span class=3D"m_5906683466233779093ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
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<label>
<span class=3D"m_5906683466233779093ss-choice-item-control m_5906683466233779093goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"PSICOLOGO" id=3D"m_5906683466233779093group_503039759_5" class=3D"m_5906683466233779093ss-q-checkbox">
</span>
<span class=3D"m_5906683466233779093ss-choice-label">
PSICOLOGO</span>
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</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_5906683466233779093errorbox-good">
<div dir=3D"auto" class=3D"m_5906683466233779093ss-item m_5906683466233779093ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_5906683466233779093ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_5906683466233779093ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"m_5906683466233779093ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
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</form>
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<tr height=3D"24px">
</tr>
</tbody>
</table>
</div>
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"max-width:672px;min-width:154px" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
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<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242;font-size:13px" target=3D"_blank" rel=3D"noreferrer">
Crea tu propio formulario de Google</a>
</td>
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</tbody>
</table>
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</div>
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