<div dir=3D"ltr">
<br>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class==3D"gmail_attr">
---------- Forwarded message ---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Formularios de Google</strong>
 <span dir=3D"auto">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: vie., 28 jun. 2019 a las 16:49<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:elizabethcorreadiaz@gmail.com">
elizabethcorreadiaz@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border==3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Formularios de Google" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por rellenar <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target=3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_3121225735824238771ss-form-container">
<div class=3D"m_3121225735824238771ss-form-heading">
<h1 class=3D"m_3121225735824238771ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_3121225735824238771ss-form-desc m_3121225735824238771ss-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_3121225735824238771ss-form">
<form method=3D"GET" id=3D"m_3121225735824238771ss-form" target=3D"_blank">
<br>
<div class=3D"m_3121225735824238771ss-form-question m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-item-required m_3121225735824238771ss-text" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3121225735824238771ss-q-item-label" for=3D"m_3121225735824238771emailAddress">
<div class=3D"m_3121225735824238771ss-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_3121225735824238771emailAddress">
</label>
<span class=3D"m_3121225735824238771ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_3121225735824238771ss-q-text m_3121225735824238771ss-printable-text-line" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
<a href=3D"mailto:elizabethcorreadiaz@gmail.com" target=3D"_blank">
elizabethcorreadiaz@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_3121225735824238771ss-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_3121225735824238771ss-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_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_3121225735824238771ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_3121225735824238771ss-page-description m_3121225735824238771ss-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_3121225735824238771ss-form-question m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-item-required m_3121225735824238771ss-text" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3121225735824238771ss-q-item-label" for=3D"m_3121225735824238771entry_579114469">
<div class=3D"m_3121225735824238771ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_3121225735824238771itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3121225735824238771ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3121225735824238771ss-q-help m_3121225735824238771ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3121225735824238771ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
ELIZABETH CORREA</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_3121225735824238771ss-form-question m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-item-required m_3121225735824238771ss-text" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3121225735824238771ss-q-item-label" for=3D"m_3121225735824238771entry_1276273985">
<div class=3D"m_3121225735824238771ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_3121225735824238771itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3121225735824238771ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3121225735824238771ss-q-help m_3121225735824238771ss-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_3121225735824238771ss-q-text" dir=3D"auto" style=3D"background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
16203285-2</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_3121225735824238771ss-form-question m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-item-required m_3121225735824238771ss-select" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3121225735824238771ss-q-item-label" for=3D"m_3121225735824238771entry_133691676">
<div class=3D"m_3121225735824238771ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_3121225735824238771itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3121225735824238771ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3121225735824238771ss-q-help m_3121225735824238771ss-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_3121225735824238771entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled selected>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_3121225735824238771ss-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_3121225735824238771ss-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_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_3121225735824238771ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_3121225735824238771ss-page-description m_3121225735824238771ss-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_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_3121225735824238771ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_3121225735824238771ss-section-description m_3121225735824238771ss-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_3121225735824238771ss-form-question m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-item-required m_3121225735824238771ss-text" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3121225735824238771ss-q-item-label" for=3D"m_3121225735824238771entry_823811303">
<div class=3D"m_3121225735824238771ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_3121225735824238771itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3121225735824238771ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3121225735824238771ss-q-help m_3121225735824238771ss-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_3121225735824238771ss-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%">
10553175-3</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_3121225735824238771ss-form-question m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-item-required m_3121225735824238771ss-text" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3121225735824238771ss-q-item-label" for=3D"m_3121225735824238771entry_1959365839">
<div class=3D"m_3121225735824238771ss-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_3121225735824238771itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3121225735824238771ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3121225735824238771ss-q-help m_3121225735824238771ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3121225735824238771ss-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%">
HECTOR BARRERA</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_3121225735824238771ss-form-question m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-item-required m_3121225735824238771ss-select" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3121225735824238771ss-q-item-label" for=3D"m_3121225735824238771entry_545002227">
<div class=3D"m_3121225735824238771ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_3121225735824238771itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3121225735824238771ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3121225735824238771ss-q-help m_3121225735824238771ss-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_3121225735824238771entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled selected>
BANMEDICA</option>
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CAPREDENA</option>
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COLMENA</option>
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CONSALUD</option>
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CRUZ BLANCA</option>
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DIPRECA</option>
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FONASA</option>
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FUNDACION</option>
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ISAPRES DEL COBRE</option>
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NUEVA MASVIDA</option>
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VIDATRES</option>
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PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_3121225735824238771ss-form-question m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-item-required m_3121225735824238771ss-text" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3121225735824238771ss-q-item-label" for=3D"m_3121225735824238771entry_1900161356">
<div class=3D"m_3121225735824238771ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_3121225735824238771itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3121225735824238771ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3121225735824238771ss-q-help m_3121225735824238771ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3121225735824238771ss-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%">
QUILPUE</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_3121225735824238771ss-form-question m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-item-required m_3121225735824238771ss-text" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3121225735824238771ss-q-item-label" for=3D"m_3121225735824238771entry_1298871758">
<div class=3D"m_3121225735824238771ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_3121225735824238771itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3121225735824238771ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3121225735824238771ss-q-help m_3121225735824238771ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3121225735824238771ss-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%">
QUILPUE</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_3121225735824238771ss-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_3121225735824238771ss-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_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_3121225735824238771ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_3121225735824238771ss-page-description m_3121225735824238771ss-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_3121225735824238771ss-form-question m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-item-required m_3121225735824238771ss-radio" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3121225735824238771ss-q-item-label" for=3D"m_3121225735824238771entry_2073233714">
<div class=3D"m_3121225735824238771ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_3121225735824238771itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3121225735824238771ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3121225735824238771ss-q-help m_3121225735824238771ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_3121225735824238771ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_3121225735824238771ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_3121225735824238771ss-choice-item-control m_3121225735824238771goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_3121225735824238771group_1222378237_1" class=3D"m_3121225735824238771ss-q-radio">
</span>
<span class=3D"m_3121225735824238771ss-choice-label">
Domicilio</span>
</label>
</li>
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<label>
<span class=3D"m_3121225735824238771ss-choice-item-control m_3121225735824238771goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_3121225735824238771group_1222378237_2" class=3D"m_3121225735824238771ss-q-radio">
</span>
<span class=3D"m_3121225735824238771ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_3121225735824238771ss-form-question m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-item-required m_3121225735824238771ss-date" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3121225735824238771ss-q-item-label" for=3D"m_3121225735824238771entry_1705849412">
<div class=3D"m_3121225735824238771ss-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_3121225735824238771itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3121225735824238771ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3121225735824238771ss-q-help m_3121225735824238771ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3121225735824238771ss-q-date">
<div class=3D"m_3121225735824238771ss-datetime-box m_3121225735824238771goog-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>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
</select>
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<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
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febrero</option>
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marzo</option>
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abril</option>
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mayo</option>
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junio</option>
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julio</option>
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agosto</option>
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septiembre</option>
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octubre</option>
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noviembre</option>
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diciembre</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_3121225735824238771entry.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_3121225735824238771ss-form-question m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-item-required m_3121225735824238771ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3121225735824238771ss-q-item-label" for=3D"m_3121225735824238771entry_206244955">
<div class=3D"m_3121225735824238771ss-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_3121225735824238771itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3121225735824238771ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3121225735824238771ss-q-help m_3121225735824238771ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3121225735824238771ss-q-time">
<div class=3D"m_3121225735824238771ss-datetime-box m_3121225735824238771goog-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_3121225735824238771entry.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>
</select>
:<select name=3D"entry.206244955_minute" disabled id=3D"m_3121225735824238771entry.206244955_minute">
<option value=3D"">
min</option>
<option value=3D"00" selected>
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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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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32</option>
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33</option>
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34</option>
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35</option>
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36</option>
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37</option>
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38</option>
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39</option>
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40</option>
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41</option>
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42</option>
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43</option>
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44</option>
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45</option>
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46</option>
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47</option>
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48</option>
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49</option>
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50</option>
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51</option>
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52</option>
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53</option>
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54</option>
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55</option>
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56</option>
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57</option>
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58</option>
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59</option>
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</div>
</div>
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<div class=3D"m_3121225735824238771ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_3121225735824238771itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3121225735824238771ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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0</option>
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1</option>
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2</option>
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3</option>
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4</option>
</select>
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</div>
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 <div class=3D"m_3121225735824238771ss-form-question m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3121225735824238771ss-q-item-label" for=3D"m_3121225735824238771entry_1716090865">
<div class=3D"m_3121225735824238771ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_3121225735824238771ss-q-help m_3121225735824238771ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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</td>
<td class=3D"m_3121225735824238771ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_3121225735824238771ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
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<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1421689035_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
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<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
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<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
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<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
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<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_3121225735824238771ss-scalenumbers" style=3D"text-align:center">
</td>
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<tr>
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</div>
</td>
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</td>
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</div>
</div>
<br>
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<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
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<div class=3D"m_3121225735824238771ss-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_3121225735824238771ss-q-help m_3121225735824238771ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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<tbody>
<tr>
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</td>
<td class=3D"m_3121225735824238771ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_3121225735824238771ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_3121225735824238771ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_3121225735824238771ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_3121225735824238771ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_3121225735824238771ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_3121225735824238771ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_3121225735824238771ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_3121225735824238771ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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<label class=3D"m_3121225735824238771ss-scalenumber" for=3D"m_3121225735824238771group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_3121225735824238771ss-scalenumbers" style=3D"text-align:center">
</td>
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<tr>
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<div class=3D"m_3121225735824238771aria-todo">
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</td>
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Escala Dolor EVA M=C3=ADnimo</div>
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0</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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9</label>
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10</label>
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PACIENTE POSTRADO SECUELADO DE TU GLIAL, RECIENTEMENTE DADO DE ALTA DE HOSPITALIZACION POR SOSPECHA DE TVP , CUADRO DESCARTADO AUNQUE SE MANTIENEN EN OBSERVACION Y BAJO TERAPIA ACO.=20SE CONFIRMA DG BAJO ESTUDIO DE LCR DE HERPES ZOSTER CON COMPROMISO OCULAR LO QUE SERIA LA CAUSA DE DOLOR OCULAR INTENSO Y EDEMA OCULAR DERECHO, ACTUALMENTE EN TTO CON XOLOFDESORIENTADO Y CON ACTITUDES ABERRANTES CARACTERISTICAS DE COMPROMISO NEUROLOGICOSE MANTIENE ESTABLE=20SIN DOLOR CON ANALGESIA TRANSDERMICA</div>
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Examen F=C3=ADsico<label for=3D"m_3121225735824238771itemView.getDomIdToLabel()">
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<span class=3D"m_3121225735824238771ss-required-asterisk" style=3D"color:#c43b1d">
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</label>
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HEMODINAMIA ESTABLECONCIENTE DURANTE ENTREVISTA, DESORIENTADO PARCIALMENTE EN TIEMPO Y ESPACIO, RECONOCE PERSONASDISARTRIA LEVE SECUNDARIA A HEMIPARESIA IZQUIERDA FACIAL CON DIFICULTAD PARA PRONUNCIACIONEXAMEN OCULAR DERECHO, EDEMA MODERADO DE GLOBO OCULAR Y ANEXOS CON SECRECION SEROHEMATICA MINIMA DE CANTO OCULAR SENSIBLE A PALPACION, VISION MINIMAMENTE REDUCIDA, PUPILA ISOCORICA REACTIVAPIEL, LESION UNICA EN REGION NASAL TIPO ULCERA CARACTERISTICA DE HERPES ZOSTER SENSIBLE, RESTO DE PIEL SIN LESIONESEDEMA FACIAL CON FASCIE CUCHINGOIDE IMPORTANTECARDIO NORMALABDOMEN BLANDO DEPRESIBLE, IMPORTANTE GANANCIA DE PESOPULMONAR NORMALEXTREMIDADES; HEMIPARESIA Y HEMIPARESTESIA IZQUIERDA CON ESCAS EVOLUCION, SE EVIDENCIA GRAN EDEMA DE EXTREMIDAD INFERIOR, SIN SIGNOS DE TVPDEPOSICIONES NORMALESDIURESIS NORMAL</div>
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*</span>
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TU GLIAL EXPANSIVO </div>
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SE HACE INCAPIE EN CUIDADOS DE ENFERMO, EN CUANTO A HIGIENE Y MANTENCIONSE CONSERVAN MEDICAMENTOS INDICADOS POR ESPECIALISTASE MANEJA DOLOR CON ANALGESIA TRANSDERMICA Y ANALGESIA SOS ORALSE MANTIENEN TERAPIAS KINESICAS TRES VECES POR SEMANA=20SE MANTIENEN CONTROL SEMANAL DE EQUIPO</div>
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<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
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<div class=3D"m_3121225735824238771ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_3121225735824238771ss-q-help m_3121225735824238771ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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SIN MODIFICACIONES</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_3121225735824238771ss-form-question m_3121225735824238771errorbox-good">
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Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_3121225735824238771ss-q-help m_3121225735824238771ss-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_3121225735824238771ss-q-date">
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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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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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diciembre</option>
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1896</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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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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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>
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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>
 <option value=3D"2055">
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>
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2062</option>
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2063</option>
 <option value==3D"2064">
2064</option>
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2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
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2068</option>
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2069</option>
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<br>
 <div class=3D"m_3121225735824238771ss-form-question m_3121225735824238771errorbox-good">
<div dir=3D"auto" class=3D"m_3121225735824238771ss-item m_3121225735824238771ss-text" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3121225735824238771ss-q-item-label" for=3D"m_3121225735824238771entry_74766472">
<div class=3D"m_3121225735824238771ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_3121225735824238771ss-q-help m_3121225735824238771ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3121225735824238771ss-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_3121225735824238771ss-item m_3121225735824238771ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_3121225735824238771ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3121225735824238771ss-q-item-label" for=3D"m_3121225735824238771entry_1219705969">
<div class=3D"m_3121225735824238771ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_3121225735824238771ss-q-help m_3121225735824238771ss-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_3121225735824238771ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
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<label>
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ENFERMERA</span>
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<label>
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<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_3121225735824238771group_503039759_2" class=3D"m_3121225735824238771ss-q-checkbox">
</span>
<span class=3D"m_3121225735824238771ss-choice-label">
TENS</span>
</label>
</li>
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<label>
<span class=3D"m_3121225735824238771ss-choice-item-control m_3121225735824238771goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"NUTRICIONISTA" id=3D"m_3121225735824238771group_503039759_3" class=3D"m_3121225735824238771ss-q-checkbox">
</span>
<span class=3D"m_3121225735824238771ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
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<label>
<span class=3D"m_3121225735824238771ss-choice-item-control m_3121225735824238771goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"KINESIOLOGO" id=3D"m_3121225735824238771group_503039759_4" class=3D"m_3121225735824238771ss-q-checkbox">
</span>
<span class=3D"m_3121225735824238771ss-choice-label">
KINESIOLOGO</span>
</label>
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<label>
<span class=3D"m_3121225735824238771ss-choice-item-control m_3121225735824238771goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"PSICOLOGO" id=3D"m_3121225735824238771group_503039759_5" class=3D"m_3121225735824238771ss-q-checkbox">
</span>
<span class=3D"m_3121225735824238771ss-choice-label">
PSICOLOGO</span>
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</div>
<br>
 <div class=3D"m_3121225735824238771errorbox-good">
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<img class=3D"m_3121225735824238771ss-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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Crea tu propio formulario de Google</a>
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