<div dir=3D"ltr">
<br clear=3D"all">
<div>
<div dir=3D"ltr" class=3D"gmail_signature" data-smartmail=3D"gmail_signature">
<div dir=3D"ltr">
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<div dir==3D"ltr">
<div>
<font size=3D"4">
<img src=3D"https://docs.google.com/uc?export=3Ddownload&amp;id=3D1CZ1y5ajpxZHYVQARdKi0pbNJ5IGsl93s&amp;revid=3D0B3qxlh9GeOnuelMreVgyS2s4Njl2YXJhY245SE9QbXA0SW5VPQ">
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</font>
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</div>
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</div>
<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: s=C3=A1b., 27 de jul. de 2019 a la(s) 10:50<br>
Subject: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
To:  &lt;<a href=3D"mailto:carolinaandrea.vsanchez@gmail.com">
carolinaandrea.vsanchez@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 llenar <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">
Estas son tus respuestas:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_-1314906873373192829ss-form-container">
<div class=3D"m_-1314906873373192829ss-form-heading">
<h1 class=3D"m_-1314906873373192829ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_-1314906873373192829ss-form-desc m_-1314906873373192829ss-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_-1314906873373192829ss-form">
<form method=3D"GET" id=3D"m_-1314906873373192829ss-form" target=3D"_blank">
<br>
<div class=3D"m_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-item-required m_-1314906873373192829ss-text" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829emailAddress">
<div class=3D"m_-1314906873373192829ss-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_-1314906873373192829emailAddress">
</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_-1314906873373192829ss-q-text m_-1314906873373192829ss-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:carolinaandrea.vsanchez@gmail.com" target=3D"_blank">
carolinaandrea.vsanchez@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-1314906873373192829ss-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_-1314906873373192829ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/00-FWRRIiJNpjLIXj1QrTLVceHhiPxWpIN-K4cI0enEtAvmFFnvOHRJTMz5Lq8yFpMHz7WvBnNdiNVchE6Snklpxxc7gIx3OoqTfn_sB2_iSp_6sx7Sr2pww-0pD" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-1314906873373192829ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_-1314906873373192829ss-page-description m_-1314906873373192829ss-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_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-item-required m_-1314906873373192829ss-text" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_579114469">
<div class=3D"m_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_-1314906873373192829itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-1314906873373192829ss-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%">
carolina Vargas</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-item-required m_-1314906873373192829ss-text" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_1276273985">
<div class=3D"m_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_-1314906873373192829itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-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_-1314906873373192829ss-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%">
17528747-7</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-item-required m_-1314906873373192829ss-select" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_133691676">
<div class=3D"m_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_-1314906873373192829itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-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_-1314906873373192829entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled selected>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-1314906873373192829ss-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_-1314906873373192829ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/mRJInQVKRU12r9blREv2jmlzETLT9JfIHWC0FaeXYfPraPFE9ebBRX8P_hmpfiBP6BNpOgjPBYU0zwBxYxgoLvjQ7EjfjoRTJ2_-8flTaiU_wC008XC8LpcEJ_Yp" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-1314906873373192829ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_-1314906873373192829ss-page-description m_-1314906873373192829ss-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_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-1314906873373192829ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_-1314906873373192829ss-section-description m_-1314906873373192829ss-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_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-item-required m_-1314906873373192829ss-text" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_823811303">
<div class=3D"m_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_-1314906873373192829itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-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_-1314906873373192829ss-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%">
1879997-9</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-item-required m_-1314906873373192829ss-text" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_1959365839">
<div class=3D"m_-1314906873373192829ss-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_-1314906873373192829itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-1314906873373192829ss-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%">
Jose  Ruiz</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-item-required m_-1314906873373192829ss-select" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_545002227">
<div class=3D"m_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_-1314906873373192829itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-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_-1314906873373192829entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
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CAPREDENA</option>
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COLMENA</option>
 <option value=3D"CONSALUD" disabled selected>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
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>
 <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_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-item-required m_-1314906873373192829ss-text" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_1900161356">
<div class=3D"m_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_-1314906873373192829itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-1314906873373192829ss-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%">
puerto montt</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-item-required m_-1314906873373192829ss-text" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_1298871758">
<div class=3D"m_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_-1314906873373192829itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-1314906873373192829ss-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%">
puerto montt</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-1314906873373192829ss-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_-1314906873373192829ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/URytM0QWRGW_JEL0xQxvOLvwPRJIHyqlnKOm6ky9DRBfzvYVPaAngXV35GNHnaVG-dm9Orno4lr8sy8E-KB9tMrmIhFbVQiOPWy3vUclqRKAJ51dvLdhjBKgXdLO" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_-1314906873373192829ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_-1314906873373192829ss-page-description m_-1314906873373192829ss-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_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-item-required m_-1314906873373192829ss-radio" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_2073233714">
<div class=3D"m_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_-1314906873373192829itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_-1314906873373192829ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-1314906873373192829ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-1314906873373192829ss-choice-item-control m_-1314906873373192829goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_-1314906873373192829group_1222378237_1" class=3D"m_-1314906873373192829ss-q-radio">
</span>
<span class=3D"m_-1314906873373192829ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_-1314906873373192829ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-1314906873373192829ss-choice-item-control m_-1314906873373192829goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_-1314906873373192829group_1222378237_2" class=3D"m_-1314906873373192829ss-q-radio">
</span>
<span class=3D"m_-1314906873373192829ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-item-required m_-1314906873373192829ss-date" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_1705849412">
<div class=3D"m_-1314906873373192829ss-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_-1314906873373192829itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-1314906873373192829ss-q-date">
<div class=3D"m_-1314906873373192829ss-datetime-box m_-1314906873373192829goog-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_-1314906873373192829ss-month-dropdown" id=3D"m_-1314906873373192829entry.1705849412_month">
<option value==3D"">
Mes</option>
<option value=3D"1">
enero</option>
 <option value=3D"2">
febrero</option>
 <option value=3D"3">
marzo</option>
 <option value=3D"4">
abril</option>
 <option value=3D"5">
mayo</option>
 <option value=3D"6">
junio</option>
 <option value==3D"7" selected>
julio</option>
 <option value=3D"8">
agosto</option>
 <option value=3D"9">
septiembre</option>
 <option value=3D"10">
octubre</option>
 <option value=3D"11">
noviembre</option>
 <option value=3D"12">
diciembre</option>
</select>
   <select name=3D"entry.1705849412_day" disabled class=3D"m_-1314906873373192829ss-day-dropdown" id=3D"m_-1314906873373192829entry.1705849412_day">
<option value=3D"">
D=C3=ADa</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">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26" selected>
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_-1314906873373192829entry.1705849412_year">
<option value=3D"">
A=C3=B1o</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_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-item-required m_-1314906873373192829ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_206244955">
<div class=3D"m_-1314906873373192829ss-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_-1314906873373192829itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-1314906873373192829ss-q-time">
<div class=3D"m_-1314906873373192829ss-datetime-box m_-1314906873373192829goog-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">
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h</option>
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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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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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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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min</option>
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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>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-item-required m_-1314906873373192829ss-select" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-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_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_-1314906873373192829itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
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</div>
</label>
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</option>
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0</option>
 <option value=3D"1" disabled>
1</option>
 <option value=3D"2" disabled selected>
2</option>
 <option value=3D"3" disabled>
3</option>
 <option value=3D"4" disabled>
4</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_1716090865">
<div class=3D"m_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-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_-1314906873373192829entry_1421689035">
<tbody>
<tr>
<td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1421689035_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1421689035_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
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<div class==3D"m_-1314906873373192829aria-todo">
</div>
</td>
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</div>
</td>
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</div>
</td>
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<div class=3D"m_-1314906873373192829ss-scalerow-fieldcell">
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</div>
</td>
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<div class=3D"m_-1314906873373192829ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3" id=3D"m_-1314906873373192829group_1421689035_4" class=3D"m_-1314906873373192829ss-q-radio">
</div>
</td>
 <td class=3D"m_-1314906873373192829ss-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_-1314906873373192829ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_-1314906873373192829group_1421689035_5" class=3D"m_-1314906873373192829ss-q-radio">
</div>
</td>
 <td class=3D"m_-1314906873373192829ss-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_-1314906873373192829ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_-1314906873373192829group_1421689035_6" class=3D"m_-1314906873373192829ss-q-radio">
</div>
</td>
 <td class=3D"m_-1314906873373192829ss-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_-1314906873373192829ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_-1314906873373192829group_1421689035_7" class=3D"m_-1314906873373192829ss-q-radio">
</div>
</td>
 <td class=3D"m_-1314906873373192829ss-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_-1314906873373192829ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"7" id=3D"m_-1314906873373192829group_1421689035_8" class=3D"m_-1314906873373192829ss-q-radio">
</div>
</td>
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<div class=3D"m_-1314906873373192829ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8" id=3D"m_-1314906873373192829group_1421689035_9" class=3D"m_-1314906873373192829ss-q-radio">
</div>
</td>
 <td class=3D"m_-1314906873373192829ss-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_-1314906873373192829ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_-1314906873373192829group_1421689035_10" class=3D"m_-1314906873373192829ss-q-radio">
</div>
</td>
 <td class=3D"m_-1314906873373192829ss-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_-1314906873373192829ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"10" id=3D"m_-1314906873373192829group_1421689035_11" class=3D"m_-1314906873373192829ss-q-radio">
</div>
</td>
<td class=3D"m_-1314906873373192829ss-scalerow m_-1314906873373192829ss-rightlabel" style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_2064050596">
<div class=3D"m_-1314906873373192829ss-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_-1314906873373192829ss-q-help m_-1314906873373192829ss-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_-1314906873373192829entry_1244707512">
<tbody>
<tr>
<td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1244707512_3" style==3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style==3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1244707512_7" style==3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
</td>
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<tr>
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<div class==3D"m_-1314906873373192829aria-todo">
</div>
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<td class=3D"m_-1314906873373192829ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
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<div class=3D"m_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=ADnimo</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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<td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
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0</label>
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1</label>
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2</label>
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<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_853118630_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
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<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_853118630_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for==3D"m_-1314906873373192829group_853118630_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_853118630_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
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 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_853118630_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_853118630_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
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<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_853118630_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_-1314906873373192829ss-scalenumber" for=3D"m_-1314906873373192829group_853118630_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_-1314906873373192829ss-scalenumbers" style=3D"text-align:center">
</td>
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<tr>
<td class=3D"m_-1314906873373192829ss-scalerow m_-1314906873373192829ss-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_-1314906873373192829aria-todo">
</div>
</td>
<td class=3D"m_-1314906873373192829ss-scalerow" style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
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</div>
</td>
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</div>
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<div class=3D"m_-1314906873373192829ss-scalerow-fieldcell">
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<br>
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<div class=3D"m_-1314906873373192829ss-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_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
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</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-1314906873373192829ss-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 en buenas condiciones generales, vigil, desorientado en tiempo y espacio, no verbaliza dolor, ni molestias.Cuidadora refiere que presenta dolor al momento de realizar las curaciones, administran paracetamol 500 mg cada 12 horas.=20Expectoraci=C3=B3n bronquial que elimina en forma espontanea, no ha requerido kinesioterapia respiratoria.=20Alimentaci=C3=B3n variada  por boca bien tolerada.Eliminaci=C3=B3n diuresis (+) Deposiciones (+) en pa=C3=B1al y ba=C3=B1o.Refieren cuadro de deposiciones liquidas el dia lunes 22.07.2019 sin mayores complicaciones.Movilidad reducida en extremidades inferiores, deambula con apoyo, se hace referencia que el usuario debe cambiar de posiciones se mantiene mas de 8 hrs sentado en la misma posici=C3=B3n.Usuario de colch=C3=B3n antiescara y cojin.Patr=C3=B3n del sue=C3=B1o normal, con apoyo farmacol=C3=B3gico.En relaci=C3=B3n a las curaciones, cuidadora refiere que presenta mayor profundidad, que las curaciones se realizan 2 veces a la semana, ap=C3=B3sito secundario lo cambian pero solo tienen gasa, menciona que hija margot esta haciendo tramites para que la isapre le aumente a 3 veces a la semana.</div>
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</div>
<br>
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<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_824006088">
<div class=3D"m_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen F=C3=ADsico<label for=3D"m_-1314906873373192829itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-1314906873373192829ss-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%">
Expectoraci=C3=B3n bronquial que elimina.Presion arterial: 152/59Pulso: 74 x&#39;Temperatura: 37=C2=B0</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-item-required m_-1314906873373192829ss-text" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_1690694733">
<div class=3D"m_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_-1314906873373192829itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-1314906873373192829ss-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%">
Ca de prostata</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-item-required m_-1314906873373192829ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_1255665248">
<div class=3D"m_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_-1314906873373192829itemView.getDomIdToLabel()">
</label>
<span class=3D"m_-1314906873373192829ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-1314906873373192829ss-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%">
Mantener tratamiento indicado por m==C3=A9dicoMantener actividades de la vida diaria (comer solo, jugar a las cartas)Realizar ejercicios en extremidades inferiores, caminar trayectos durante el dia.En periodos de descanso extremidades en alto.Valorar caracter=C3=ADsticas del dolor, administrar analgesia indicada por m=C3=A9dico.Refuerzo de ap=C3=B3sito secundario cada vez que sea necesario, ap=C3=B3sito tradicional que logre absorber exudado (se hace hincapi=C3=A9 que el ap==C3=B3sito secundario debe ser absorbente, no gasa)Ademas se educa en la necesidad de realizar el cambio de posicion y no mantener mas de 2 hrs sentado, ya que a pesar de que le realicen las curaciones, mantienen la presi=C3=B3n en la zona de la UPP.Mantener alimentaci=C3=B3n seg=C3=BAn indicaci=C3=B3n de nutricionista.En caso de s=C3=ADntomas/signos de cuadro agudo informar o acudir a CPM.</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_1648939075">
<div class=3D"m_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-1314906873373192829ss-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>
 <div class=3D"m_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-date" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_2063615873">
<div class=3D"m_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-1314906873373192829ss-q-date">
<div class=3D"m_-1314906873373192829ss-datetime-box m_-1314906873373192829goog-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.2063615873_month" disabled class=3D"m_-1314906873373192829ss-month-dropdown" id=3D"m_-1314906873373192829entry.2063615873_month">
<option value==3D"">
Mes</option>
<option value=3D"1">
enero</option>
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febrero</option>
 <option value=3D"3">
marzo</option>
 <option value=3D"4">
abril</option>
 <option value=3D"5">
mayo</option>
 <option value=3D"6">
junio</option>
 <option value==3D"7">
julio</option>
 <option value=3D"8" selected>
agosto</option>
 <option value=3D"9">
septiembre</option>
 <option value=3D"10">
octubre</option>
 <option value=3D"11">
noviembre</option>
 <option value=3D"12">
diciembre</option>
</select>
   <select name=3D"entry.2063615873_day" disabled class=3D"m_-1314906873373192829ss-day-dropdown" id=3D"m_-1314906873373192829entry.2063615873_day">
<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
 <option value=3D"2" selected>
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">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
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29</option>
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30</option>
 <option value=3D"31">
31</option>
</select>
=20<select name=3D"entry.2063615873_year" disabled id=3D"m_-1314906873373192829entry.2063615873_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
 <option value=3D"1898">
1898</option>
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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>
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2028</option>
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2029</option>
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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_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-text" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_74766472">
<div class=3D"m_-1314906873373192829ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_-1314906873373192829ss-q-help m_-1314906873373192829ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_-1314906873373192829ss-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>
 <div class=3D"m_-1314906873373192829ss-form-question m_-1314906873373192829errorbox-good">
<div dir=3D"auto" class=3D"m_-1314906873373192829ss-item m_-1314906873373192829ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_-1314906873373192829ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_-1314906873373192829ss-q-item-label" for=3D"m_-1314906873373192829entry_1219705969">
<div class=3D"m_-1314906873373192829ss-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_-1314906873373192829ss-q-help m_-1314906873373192829ss-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_-1314906873373192829ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_-1314906873373192829ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_-1314906873373192829ss-choice-item-control m_-1314906873373192829goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"ENFERMERA" id=3D"m_-1314906873373192829group_503039759_1" class=3D"m_-1314906873373192829ss-q-checkbox">
</span>
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<img class=3D"m_-1314906873373192829ss-image" title=3D"" src=3D"https://lh5.googleusercontent.com/Bpur5zPteyG-bXtM-WNRuiLwTi8myvetX7lBkdjzbnQyqUlGcuv84zmWyU3x0Ua2-_WXX9PiJ2cMBOO0zhG2nHX7tXXPHH6_X8UTG8MZzIBwxETkF0a8JyZtuxSL" style=3D"width:78px;outline:none" alt=3D"Imagen sin t=C3=ADtulo">
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