<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">
Google Forms</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: s=C3=A1b., 20 jul. 2019 a las 11:58<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:vivimoragam@gmail.com">
vivimoragam@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"Google Forms" 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">
Thanks for filling out <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">
Here&#39;s what we got from you:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_-4014896242219530497ss-form-container">
<div class=3D"m_-4014896242219530497ss-form-heading">
<h1 class=3D"m_-4014896242219530497ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_-4014896242219530497ss-form-desc m_-4014896242219530497ss-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_-4014896242219530497ss-form">
<form method=3D"GET" id=3D"m_-4014896242219530497ss-form" target=3D"_blank">
<br>
<div class=3D"m_-4014896242219530497ss-form-question m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-item-required m_-4014896242219530497ss-text" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4014896242219530497ss-q-item-label" for=3D"m_-4014896242219530497emailAddress">
<div class=3D"m_-4014896242219530497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Email address<label for=3D"m_-4014896242219530497emailAddress">
</label>
<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_-4014896242219530497ss-q-text m_-4014896242219530497ss-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:vivimoragam@gmail.com" target=3D"_blank">
vivimoragam@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-4014896242219530497ss-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_-4014896242219530497ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-4014896242219530497ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_-4014896242219530497ss-page-description m_-4014896242219530497ss-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_-4014896242219530497ss-form-question m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-item-required m_-4014896242219530497ss-text" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4014896242219530497ss-q-item-label" for=3D"m_-4014896242219530497entry_579114469">
<div class=3D"m_-4014896242219530497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_-4014896242219530497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4014896242219530497ss-q-help m_-4014896242219530497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4014896242219530497ss-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%">
Viviana Moraga</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4014896242219530497ss-form-question m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-item-required m_-4014896242219530497ss-text" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4014896242219530497ss-q-item-label" for=3D"m_-4014896242219530497entry_1276273985">
<div class=3D"m_-4014896242219530497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_-4014896242219530497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4014896242219530497ss-q-help m_-4014896242219530497ss-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_-4014896242219530497ss-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%">
18121502-k</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4014896242219530497ss-form-question m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-item-required m_-4014896242219530497ss-select" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4014896242219530497ss-q-item-label" for=3D"m_-4014896242219530497entry_133691676">
<div class=3D"m_-4014896242219530497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_-4014896242219530497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4014896242219530497ss-q-help m_-4014896242219530497ss-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_-4014896242219530497entry_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_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-4014896242219530497ss-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_-4014896242219530497ss-image" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-4014896242219530497ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_-4014896242219530497ss-page-description m_-4014896242219530497ss-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_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-4014896242219530497ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_-4014896242219530497ss-section-description m_-4014896242219530497ss-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_-4014896242219530497ss-form-question m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-item-required m_-4014896242219530497ss-text" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4014896242219530497ss-q-item-label" for=3D"m_-4014896242219530497entry_823811303">
<div class=3D"m_-4014896242219530497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_-4014896242219530497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4014896242219530497ss-q-help m_-4014896242219530497ss-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_-4014896242219530497ss-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%">
3602556-5</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4014896242219530497ss-form-question m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-item-required m_-4014896242219530497ss-text" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4014896242219530497ss-q-item-label" for=3D"m_-4014896242219530497entry_1959365839">
<div class=3D"m_-4014896242219530497ss-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_-4014896242219530497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4014896242219530497ss-q-help m_-4014896242219530497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4014896242219530497ss-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%">
Mar=C3=ADa romero </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4014896242219530497ss-form-question m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-item-required m_-4014896242219530497ss-select" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4014896242219530497ss-q-item-label" for=3D"m_-4014896242219530497entry_545002227">
<div class=3D"m_-4014896242219530497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_-4014896242219530497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4014896242219530497ss-q-help m_-4014896242219530497ss-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_-4014896242219530497entry_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 selected>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled>
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled>
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4014896242219530497ss-form-question m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-item-required m_-4014896242219530497ss-text" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4014896242219530497ss-q-item-label" for=3D"m_-4014896242219530497entry_1900161356">
<div class=3D"m_-4014896242219530497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_-4014896242219530497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4014896242219530497ss-q-help m_-4014896242219530497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4014896242219530497ss-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%">
Concepci=C3=B3n</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4014896242219530497ss-form-question m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-item-required m_-4014896242219530497ss-text" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4014896242219530497ss-q-item-label" for=3D"m_-4014896242219530497entry_1298871758">
<div class=3D"m_-4014896242219530497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_-4014896242219530497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4014896242219530497ss-q-help m_-4014896242219530497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4014896242219530497ss-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%">
Concepci=C3=B3n</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-4014896242219530497ss-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_-4014896242219530497ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-4014896242219530497ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_-4014896242219530497ss-page-description m_-4014896242219530497ss-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_-4014896242219530497ss-form-question m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-item-required m_-4014896242219530497ss-radio" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4014896242219530497ss-q-item-label" for=3D"m_-4014896242219530497entry_2073233714">
<div class=3D"m_-4014896242219530497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_-4014896242219530497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4014896242219530497ss-q-help m_-4014896242219530497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_-4014896242219530497ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-4014896242219530497ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-4014896242219530497ss-choice-item-control m_-4014896242219530497goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_-4014896242219530497group_1222378237_1" class=3D"m_-4014896242219530497ss-q-radio">
</span>
<span class=3D"m_-4014896242219530497ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_-4014896242219530497ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-4014896242219530497ss-choice-item-control m_-4014896242219530497goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_-4014896242219530497group_1222378237_2" class=3D"m_-4014896242219530497ss-q-radio">
</span>
<span class=3D"m_-4014896242219530497ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4014896242219530497ss-form-question m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-item-required m_-4014896242219530497ss-date" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4014896242219530497ss-q-item-label" for=3D"m_-4014896242219530497entry_1705849412">
<div class=3D"m_-4014896242219530497ss-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_-4014896242219530497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4014896242219530497ss-q-help m_-4014896242219530497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4014896242219530497ss-q-date">
<div class=3D"m_-4014896242219530497ss-datetime-box m_-4014896242219530497goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name=3D"entry.1705849412_month" disabled class=3D"m_-4014896242219530497ss-month-dropdown" id=3D"m_-4014896242219530497entry.1705849412_month">
<option value==3D"">
Month</option>
<option value=3D"1">
January</option>
 <option value=3D"2">
February</option>
 <option value=3D"3">
March</option>
 <option value=3D"4">
April</option>
 <option value=3D"5">
May</option>
 <option value=3D"6">
June</option>
 <option value=3D"7" selected>
July</option>
 <option value=3D"8">
August</option>
 <option value=3D"9">
September</option>
 <option value=3D"10">
October</option>
 <option value=3D"11">
November</option>
 <option value=3D"12">
December</option>
</select>
   <select name=3D"entry.1705849412_day" disabled class=3D"m_-4014896242219530497ss-day-dropdown" id=3D"m_-4014896242219530497entry.1705849412_day">
<option value=3D"">
Day</option>
<option value=3D"1">
1</option>
 <option value=3D"2">
2</option>
 <option value=3D"3">
3</option>
 <option value=3D"4">
4</option>
 <option value=3D"5">
5</option>
 <option value=3D"6">
6</option>
 <option value=3D"7">
7</option>
 <option value=3D"8">
8</option>
 <option value=3D"9">
9</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" selected>
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
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23</option>
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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>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_-4014896242219530497entry.1705849412_year">
<option value=3D"">
Year</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
 <option value=3D"1898">
1898</option>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
1901</option>
 <option value=3D"1902">
1902</option>
 <option value=3D"1903">
1903</option>
 <option value=3D"1904">
1904</option>
 <option value=3D"1905">
1905</option>
 <option value=3D"1906">
1906</option>
 <option value=3D"1907">
1907</option>
 <option value=3D"1908">
1908</option>
 <option value=3D"1909">
1909</option>
 <option value=3D"1910">
1910</option>
 <option value=3D"1911">
1911</option>
 <option value=3D"1912">
1912</option>
 <option value=3D"1913">
1913</option>
 <option value=3D"1914">
1914</option>
 <option value=3D"1915">
1915</option>
 <option value=3D"1916">
1916</option>
 <option value=3D"1917">
1917</option>
 <option value=3D"1918">
1918</option>
 <option value=3D"1919">
1919</option>
 <option value=3D"1920">
1920</option>
 <option value=3D"1921">
1921</option>
 <option value=3D"1922">
1922</option>
 <option value=3D"1923">
1923</option>
 <option value==3D"1924">
1924</option>
 <option value=3D"1925">
1925</option>
 <option value==3D"1926">
1926</option>
 <option value=3D"1927">
1927</option>
 <option value==3D"1928">
1928</option>
 <option value=3D"1929">
1929</option>
 <option value==3D"1930">
1930</option>
 <option value=3D"1931">
1931</option>
 <option value==3D"1932">
1932</option>
 <option value=3D"1933">
1933</option>
 <option value==3D"1934">
1934</option>
 <option value=3D"1935">
1935</option>
 <option value==3D"1936">
1936</option>
 <option value=3D"1937">
1937</option>
 <option value==3D"1938">
1938</option>
 <option value=3D"1939">
1939</option>
 <option value==3D"1940">
1940</option>
 <option value=3D"1941">
1941</option>
 <option value==3D"1942">
1942</option>
 <option value=3D"1943">
1943</option>
 <option value==3D"1944">
1944</option>
 <option value=3D"1945">
1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
1948</option>
 <option value=3D"1949">
1949</option>
 <option value==3D"1950">
1950</option>
 <option value=3D"1951">
1951</option>
 <option value==3D"1952">
1952</option>
 <option value=3D"1953">
1953</option>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
 <option value=3D"1959">
1959</option>
 <option value==3D"1960">
1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
1976</option>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
 <option value==3D"1980">
1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
 <option value==3D"1990">
1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
 <option value=3D"2011">
2011</option>
 <option value==3D"2012">
2012</option>
 <option value=3D"2013">
2013</option>
 <option value==3D"2014">
2014</option>
 <option value=3D"2015">
2015</option>
 <option value==3D"2016">
2016</option>
 <option value=3D"2017">
2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
2061</option>
 <option value==3D"2062">
2062</option>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4014896242219530497ss-form-question m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-item-required m_-4014896242219530497ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4014896242219530497ss-q-item-label" for=3D"m_-4014896242219530497entry_206244955">
<div class=3D"m_-4014896242219530497ss-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_-4014896242219530497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4014896242219530497ss-q-help m_-4014896242219530497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4014896242219530497ss-q-time">
<div class=3D"m_-4014896242219530497ss-datetime-box m_-4014896242219530497goog-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_-4014896242219530497entry.206244955_hour">
<option value=3D"">
Hr</option>
<option value=3D"01">
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>
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09</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
</select>
:<select name=3D"entry.206244955_minute" disabled id=3D"m_-4014896242219530497entry.206244955_minute">
<option value=3D"">
Min</option>
<option value=3D"00" selected>
00</option>
 <option value=3D"01">
01</option>
 <option value=3D"02">
02</option>
 <option value=3D"03">
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>
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19</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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<select name=3D"entry.206244955_ampm" disabled>
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AM</option>
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PM</option>
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</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4014896242219530497ss-form-question m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-item-required m_-4014896242219530497ss-select" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-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_-4014896242219530497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_-4014896242219530497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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</div>
</label>
<select name=3D"entry.1747608258" disabled id=3D"m_-4014896242219530497entry_1747608258">
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</option>
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0</option>
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1</option>
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2</option>
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3</option>
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4</option>
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</div>
</div>
<br>
 <div class=3D"m_-4014896242219530497ss-form-question m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4014896242219530497ss-q-item-label" for=3D"m_-4014896242219530497entry_1716090865">
<div class=3D"m_-4014896242219530497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_-4014896242219530497ss-q-help m_-4014896242219530497ss-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_-4014896242219530497entry_1421689035">
<tbody>
<tr>
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</td>
<td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1421689035_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
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<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1421689035_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-4014896242219530497ss-scalerow m_-4014896242219530497ss-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_-4014896242219530497aria-todo">
</div>
</td>
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</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"1" id=3D"m_-4014896242219530497group_1421689035_2" class=3D"m_-4014896242219530497ss-q-radio">
</div>
</td>
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"2" id=3D"m_-4014896242219530497group_1421689035_3" class=3D"m_-4014896242219530497ss-q-radio">
</div>
</td>
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<div class=3D"m_-4014896242219530497ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3" id=3D"m_-4014896242219530497group_1421689035_4" class=3D"m_-4014896242219530497ss-q-radio">
</div>
</td>
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<div class=3D"m_-4014896242219530497ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_-4014896242219530497group_1421689035_5" class=3D"m_-4014896242219530497ss-q-radio">
</div>
</td>
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<div class=3D"m_-4014896242219530497ss-scalerow-fieldcell">
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<div class=3D"m_-4014896242219530497ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_-4014896242219530497group_1421689035_7" class=3D"m_-4014896242219530497ss-q-radio">
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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_-4014896242219530497group_1421689035_9" class=3D"m_-4014896242219530497ss-q-radio">
</div>
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<div class=3D"m_-4014896242219530497ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_-4014896242219530497group_1421689035_10" class=3D"m_-4014896242219530497ss-q-radio">
</div>
</td>
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<div class=3D"m_-4014896242219530497ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"10" id=3D"m_-4014896242219530497group_1421689035_11" class=3D"m_-4014896242219530497ss-q-radio">
</div>
</td>
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</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_-4014896242219530497ss-form-question m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4014896242219530497ss-q-item-label" for=3D"m_-4014896242219530497entry_2064050596">
<div class=3D"m_-4014896242219530497ss-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_-4014896242219530497ss-q-help m_-4014896242219530497ss-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_-4014896242219530497entry_1244707512">
<tbody>
<tr>
<td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1244707512_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1244707512_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-4014896242219530497ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
<td class=3D"m_-4014896242219530497ss-scalerow m_-4014896242219530497ss-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_-4014896242219530497aria-todo">
</div>
</td>
<td class=3D"m_-4014896242219530497ss-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_-4014896242219530497ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"0" id=3D"m_-4014896242219530497group_1244707512_1" class=3D"m_-4014896242219530497ss-q-radio">
</div>
</td>
 <td class=3D"m_-4014896242219530497ss-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_-4014896242219530497ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"1" id=3D"m_-4014896242219530497group_1244707512_2" class=3D"m_-4014896242219530497ss-q-radio">
</div>
</td>
 <td class=3D"m_-4014896242219530497ss-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_-4014896242219530497ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"2" id=3D"m_-4014896242219530497group_1244707512_3" class==3D"m_-4014896242219530497ss-q-radio">
</div>
</td>
 <td class=3D"m_-4014896242219530497ss-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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Escala Dolor EVA M=C3=ADnimo</div>
<div class=3D"m_-4014896242219530497ss-q-help m_-4014896242219530497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_853118630_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-4014896242219530497ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_853118630_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
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<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_853118630_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
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<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_853118630_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
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<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_853118630_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
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<label class=3D"m_-4014896242219530497ss-scalenumber" for==3D"m_-4014896242219530497group_853118630_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
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<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_853118630_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
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7</label>
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8</label>
</td>
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<label class=3D"m_-4014896242219530497ss-scalenumber" for=3D"m_-4014896242219530497group_853118630_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
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10</label>
</td>
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</td>
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<tr>
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<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"7" id=3D"m_-4014896242219530497group_853118630_8" class==3D"m_-4014896242219530497ss-q-radio">
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Anamnesis/Evoluci=C3=B3n<label for=3D"m_-4014896242219530497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4014896242219530497ss-q-help m_-4014896242219530497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4014896242219530497ss-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%">
Paciente acompa=C3=B1ada por hermana, hijo y personal de la residencia.Con apetito conservado, de buen =C3=A1nimo, discretamente cansada. Refiere que hace 1 semana aprox ha presentado episodios de incontinencia fecal principalmente durante las noches, sin diarrea, sin dolor abdominal, con deposiciones semiformadas diarias.Persiste con debilidad extremidad superior derecha, ya sin dolor.Sin nuevos episodios de sangrado.Tuvo control nutricional reciente, con baja de peso 2 kg aprox en 1 semana, que coincide con disminuci=C3=B3n marcada de edema de eeii</div>
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<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4014896242219530497ss-q-item-label" for=3D"m_-4014896242219530497entry_824006088">
<div class=3D"m_-4014896242219530497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen F=C3=ADsico<label for=3D"m_-4014896242219530497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
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</div>
</label>
<div class=3D"m_-4014896242219530497ss-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%">
BEG, signos vitales normales, vigil, orientada, de buen =C3=A1nimo.=20Bien hidratada y perfundida, mucosas p=C3=A1lidas, cav oral sin lesiones. Sin adenopat=C3=ADas cervicales palpables, yugulares planas. RI2T sin soplos audibles, MP + SRA. Abd RHA +, depresible, indoloro, sin masas ni visceromegalias palpables. Piel sana sin lesiones, con equ=C3=ADmosis ESD en regresi=C3=B3n. Peque=C3=B1a maceraci=C3=B3n de pliegue entre labio mayor y zona inguinal izq, sin soluci=C3=B3n de continuidad. Extremidades inferiores con edema escaso sim=C3=A9trico, marcadamente menor en relaci=C3=B3n a evaluaciones previas.Fuerza de EESS M5 izq M4 der. </div>
</div>
</div>
</div>
<br>
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<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-item-required m_-4014896242219530497ss-text" style=3D"margin:12px 0">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-4014896242219530497ss-q-item-label" for=3D"m_-4014896242219530497entry_1690694733">
<div class=3D"m_-4014896242219530497ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_-4014896242219530497itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-4014896242219530497ss-q-help m_-4014896242219530497ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-4014896242219530497ss-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%">
Tumor renal derecho, obs c=C3=A1 renal. Insuficiencia card=C3=ADaca cr=C3=B3nica. Fibrilaci=C3=B3n auricular con control de frecuencia. Hipertensi=C3=B3n arterial. Hipotiroidismo. Insomnio de conciliaci=C3=B3n. Hiponatremia leve (probablemente secundaria a insuficiencia card=C3=ADaca). Pancitopenia.</div>
</div>
</div>
</div>
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Plan de Tratamiento e Indicaciones<label for=3D"m_-4014896242219530497itemView.getDomIdToLabel()">
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<span class=3D"m_-4014896242219530497ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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1) Observar nuevos episodios de sangrado 2) Mantener precauciones de UPP 3) Mantener analgesia 4) Mantener indicaciones por nutricionista y enfermero y enfermera</div>
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<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-paragraph-text" style=3D"margin:12px 0">
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Medicamentos Indicados</div>
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1)	Buprenorfina 35ug,1 parche cada 3 d=C3=ADas (ir rotando zona de aplicaci=C3=B3n)2)	Metamizol 300mg/12hrs vo=203)	Tramadol 10 gotas vo SOS=204)	Bisoprolol 5 mg/d=C3=ADa vo (dosis modificada por m=C3=A9dico de atenci==C3=B3n de urgencias el 15/05/19)5)	Olmesart=C3=A1n 20mg/d=C3=ADa vo (dosis modificada por cardi=C3=B3logo tratante)6)	Levotiroxina 25ug/d=C3=ADa vo (al menos media hr antes del desayuno)=207)	Escitalopran 10mg/d=C3=ADa vo=208)	Zolpidem 10mg/noche vo=209)	Furosemida 40mg am, 20 mg pm  vo (dosis modificada por cardi=C3=B3logo tratante)10)	Vitamina C, 1 comp efervescente al d=C3=ADa vo=2011)	Centrum silver 1 comp/d=C3=ADa vo=2012)	Lactulosa jarabe, 10-30cc/6-8hrs, lo necesario para 2-3 deposiciones semiformadas al d=C3=ADa13) Metoclopramida 10mg vo con el desayuno y almuerzo14) Quetiapina 25mg, 1,5 comp/noche (indicaci=C3=B3n de psiquiatra particular)</div>
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Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
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<div class=3D"m_-4014896242219530497ss-datetime-box m_-4014896242219530497goog-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"">
Month</option>
<option value=3D"1">
January</option>
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February</option>
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March</option>
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April</option>
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May</option>
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June</option>
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July</option>
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August</option>
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September</option>
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October</option>
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November</option>
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December</option>
</select>
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Day</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>
 <option value=3D"26" selected>
26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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<option value=3D"">
Year</option>
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1896</option>
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1897</option>
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1898</option>
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1899</option>
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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>
 <option value=3D"1919">
1919</option>
 <option value=3D"1920">
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>
 <option value==3D"1958">
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>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
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Tratamiento Realizado (si corresponde)</div>
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<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
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Derivaci=C3=B3n a otro Prestador Domiciliario</div>
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S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
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<input type=3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"ENFERMERA" id=3D"m_-4014896242219530497group_503039759_1" class=3D"m_-4014896242219530497ss-q-checkbox">
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ENFERMERA</span>
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<label>
<span class=3D"m_-4014896242219530497ss-choice-item-control m_-4014896242219530497goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_-4014896242219530497group_503039759_2" class=3D"m_-4014896242219530497ss-q-checkbox">
</span>
<span class=3D"m_-4014896242219530497ss-choice-label">
TENS</span>
</label>
</li>
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<label>
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<input type=3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"NUTRICIONISTA" id=3D"m_-4014896242219530497group_503039759_3" class=3D"m_-4014896242219530497ss-q-checkbox">
</span>
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NUTRICIONISTA</span>
</label>
</li>
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<label>
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<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"KINESIOLOGO" id=3D"m_-4014896242219530497group_503039759_4" class=3D"m_-4014896242219530497ss-q-checkbox">
</span>
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KINESIOLOGO</span>
</label>
</li>
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<label>
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<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"PSICOLOGO" id=3D"m_-4014896242219530497group_503039759_5" class=3D"m_-4014896242219530497ss-q-checkbox">
</span>
<span class=3D"m_-4014896242219530497ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
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</div>
<br>
 <div class=3D"m_-4014896242219530497errorbox-good">
<div dir=3D"auto" class=3D"m_-4014896242219530497ss-item m_-4014896242219530497ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-4014896242219530497ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-4014896242219530497ss-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_-4014896242219530497ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
</form>
</div>
</div>
</td>
</tr>
<tr height=3D"24px">
</tr>
</tbody>
</table>
</div>
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"max-width:672px;min-width:154px" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242;font-size:13px" target=3D"_blank">
Create your own Google Form</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
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