X-AntiAbuse: Primary Hostname - ns1.hostnow.clX-AntiAbuse: Original Domain - telemed-chile.clX-AntiAbuse: Originator/Caller UID/GID - [47 12] / [47 12]X-AntiAbuse: Sender Address Domain - telemed-chile.clX-Get-Message-Sender-Via: ns1.hostnow.cl: authenticated_id: claritamamani@telemed-chile.clX-Authenticated-Sender: ns1.hostnow.cl: claritamamani@telemed-chile.clX-Source: X-Source-Args: X-Source-Dir: X-Spam-Status: Yes, score=6.6X-Spam-Score: 66X-Spam-Bar: ++++++X-Spam-Report: Spam detection software, running on the system "host213.hostmonster.com", has identified this incoming email as possible spam.  The original message has been attached to this so you can view it or label similar future email.  If you have any questions, see root\@localhost for details.  Content preview:  Buenas tardes junto con saludar reenvío registro de atención    realizada a la paciente Saludos cordiales Atentamente Clara Mamani   Content analysis details:   (6.6 points, 5.0 required)   pts rule name              description ---- ---------------------- --------------------------------------------------  0.0 URIBL_BLOCKED          ADMINISTRATOR NOTICE: The query to URIBL was                             blocked.  See                             http://wiki.apache.org/spamassassin/DnsBlocklists#dnsbl-block                              for more information.                             [URIs: docs.google.com]  0.9 SPF_HELO_SOFTFAIL      SPF: HELO does not match SPF record (softfail)  1.5 SUBJ_ALL_CAPS          Subject is all capitals -0.5 SPF_PASS               SPF: sender matches SPF record  0.0 HTML_MESSAGE           BODY: HTML included in message  2.4 HTML_OBFUSCATE_20_30   BODY: Message is 20% to 30% HTML                             obfuscation  0.1 MIME_HTML_ONLY         BODY: Message only has text/html MIME parts -0.1 DKIM_VALID_AU          Message has a valid DKIM or DK signature from                             author's domain  0.1 DKIM_SIGNED            Message has a DKIM or DK signature, not necessarily                             valid -0.1 DKIM_VALID             Message has at least one valid DKIM or DK signature -0.1 DKIM_VALID_EF          Message has a valid DKIM or DK signature from                             envelope-from domain  0.6 HTML_MIME_NO_HTML_TAG  HTML-only message, but there is no HTML                             tag  1.8 MISSING_MIMEOLE        Message has X-MSMail-Priority, but no X-MimeOLE -0.1 AWL                    AWL: Adjusted score from AWL reputation of From: addressX-Spam-Flag: NO<div dir='auto'>
Buenas tardes junto con saludar reenvío registro de atención realizada a la paciente<div dir="auto">
Saludos cordiales&nbsp;</div>
<div dir="auto">
Atentamente&nbsp;</div>
<div dir="auto">
Clara Mamani&nbsp;</div>
<div dir="auto">
Enfermera&nbsp;</div>
</div>
<div class="gmail_quote">
---------- Mensaje reenviado ----------<br>
De: Formularios de Google &lt;forms-receipts-noreply@google.com&gt;<br>
Fecha: 27-07-2019 09:49<br>
Asunto: Registro de Atención Domiciliaria Oncovida<br>
Para: claritamamani@telemed-chile.cl<br>
Cc: <br>
<br type="attribution" />
<blockquote class="quote" style="margin:0 0 0 .8ex;border-left:1px #ccc solid;padding-left:1ex">
<div style="font-family:&#39;roboto&#39; , &#39;helvetica&#39; , &#39;arial&#39; , sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border="0" cellpadding="0" cellspacing="0" style="background-color:rgb( 38 , 4 , 154 )" width="100%">
<tbody>
<tr>
<td style="padding-left:24px">
<img alt="Formularios de Google" height="26px" style="display:inline-block;margin:0;vertical-align:middle" width="143px" src="https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png" />
</td>
</tr>
</tbody>
</table>
<div style="padding:24px;background-color:rgb( 229 , 218 , 254 )">
<div align="center" style="background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align="center" cellpadding="0" cellspacing="0" style="background-color:#fff" width="100%">
<tbody>
<tr>
<td>
</td>
</tr>
<tr>
<td>
<div style="font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por llenar <a href="https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp&#61;mail_form_link">
Registro de Atención Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr>
</tr>
<tr>
<td>
<div style="font-size:13px;line-height:18px;color:#424242">
Estas son tus respuestas:</div>
</td>
</tr>
<tr>
<td>
<div>
<div>
<h1 dir="ltr" style="margin:0.67em 0">
Registro de Atención Domiciliaria Oncovida</h1>

<div style="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 continuación indique su correo electrónico.</div>

</div>

<div>
<form action="" method="GET">
<br />

<div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Dirección de correo electrónico
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>
</label>

<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
claritamamani&#64;telemed-chile.cl</div>



</div>
</div>
</div>

<div>

<div dir="auto" style="margin:12px 0;max-width:100%">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
</h2>

<div style="text-align:right">
<img src="https://lh3.googleusercontent.com/00-FWRRIiJNpjLIXj1QrTLVceHhiPxWpIN-K4cI0enEtAvmFFnvOHRJTMz5Lq8yFpMHz7WvBnNdiNVchE6Snklpxxc7gIx3OoqTfn_sB2_iSp_6sx7Sr2pww-0pD" style="width:78px;outline:none" alt="Imagen sin título" />
</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="margin:2em 0;padding:0.4em;background-color:#eee">
Identificación del Prestador</h2>

<div dir="auto" style="white-space:pre-wrap;word-wrap:break-word">
Aquí debe ingresar sus datos personales</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Primer Nombre y Apellido Paterno
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>
</label>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
CLARA MAMANI</div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
RUT
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
18787490-4</div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Tipo
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
Si asisten más de 1 prestador simultáneamente, cada uno debe hacer un registro independiente</div>
</label>


<select name="entry.133691676" disabled="disabled">
<option value="">
</option>
<option value="MEDICO" disabled="disabled">
MEDICO</option>
<option value="ENFERMERA/O" disabled="disabled" selected="selected">
ENFERMERA/O</option>
<option value="TENS" disabled="disabled">
TENS</option>
<option value="KINESIOLOGA/O" disabled="disabled">
KINESIOLOGA/O</option>
<option value="PSICOLOGO" disabled="disabled">
PSICOLOGO</option>
<option value="NUTRICIONISTA" disabled="disabled">
NUTRICIONISTA</option>
</select>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0;max-width:100%">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
</h2>

<div style="text-align:right">
<img src="https://lh3.googleusercontent.com/mRJInQVKRU12r9blREv2jmlzETLT9JfIHWC0FaeXYfPraPFE9ebBRX8P_hmpfiBP6BNpOgjPBYU0zwBxYxgoLvjQ7EjfjoRTJ2_-8flTaiU_wC008XC8LpcEJ_Yp" style="width:78px;outline:none" alt="Imagen sin título" />
</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="margin:2em 0;padding:0.4em;background-color:#eee">
Identificación del Paciente</h2>

<div dir="auto" style="white-space:pre-wrap;word-wrap:break-word">
En esta sección debe ingresar los datos del paciente visitado</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="background-color:#eee;padding:0.4em;margin:2em 0">
Datos Personales del Paciente</h2>

<div style="margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word">
</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Ingrese el Rut del Paciente
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
RUT con Guión y Dígito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
13447818-7</div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>
</label>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
SONIA ARAOS</div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Previsión
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>
</label>


<select name="entry.545002227" disabled="disabled">
<option value="">
</option>
<option value="BANMEDICA" disabled="disabled">
BANMEDICA</option>
<option value="CAPREDENA" disabled="disabled">
CAPREDENA</option>
<option value="COLMENA" disabled="disabled" selected="selected">
COLMENA</option>
<option value="CONSALUD" disabled="disabled">
CONSALUD</option>
<option value="CRUZ BLANCA" disabled="disabled">
CRUZ BLANCA</option>
<option value="DIPRECA" disabled="disabled">
DIPRECA</option>
<option value="FONASA" disabled="disabled">
FONASA</option>
<option value="FUNDACION" disabled="disabled">
FUNDACION</option>
<option value="ISAPRES DEL COBRE" disabled="disabled">
ISAPRES DEL COBRE</option>
<option value="NUEVA MASVIDA" disabled="disabled">
NUEVA MASVIDA</option>
<option value="VIDATRES" disabled="disabled">
VIDATRES</option>
<option value="PARTICULAR" disabled="disabled">
PARTICULAR</option>
</select>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Ciudad
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>
</label>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
ARICA</div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Comuna
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>
</label>


<div dir="auto" style="background-color:#eee;max-width:90%;border:1px solid #c0c0c0;padding:5px;white-space:pre-wrap;color:#545454;width:70%">
ARICA</div>



</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0;max-width:100%">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
</h2>

<div style="text-align:right">
<img src="https://lh6.googleusercontent.com/URytM0QWRGW_JEL0xQxvOLvwPRJIHyqlnKOm6ky9DRBfzvYVPaAngXV35GNHnaVG-dm9Orno4lr8sy8E-KB9tMrmIhFbVQiOPWy3vUclqRKAJ51dvLdhjBKgXdLO" style="width:78px;outline:none" alt="Imagen sin título" />
</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="margin:2em 0;padding:0.4em;background-color:#eee">
Registro de la Atención Domiciliaria</h2>

<div dir="auto" style="white-space:pre-wrap;word-wrap:break-word">
En esta sección debe ingresar los datos de la atención domiciliaria</div>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Tipo de Atención
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>
</label>



<ul style="list-style:none;padding:0;margin:0.5em 0 0">
<li style="margin:0;line-height:1.3em;padding-bottom:0.5em">

<label>
<span style="display:inline-block">
<input type="radio" name="entry.1222378237" disabled="disabled" checked="checked" value="Domicilio" />
</span>

Domicilio
</label>
</li>
<li style="margin:0;line-height:1.3em;padding-bottom:0.5em">

<label>
<span style="display:inline-block">
<input type="radio" name="entry.1222378237" disabled="disabled" value="Ambulatorio" />
</span>

Ambulatorio
</label>
</li>
</ul>


</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Fecha de la Atención
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>
</label>


<div>
<div style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
 <select name="entry.1705849412_month" disabled="disabled">
<option value="">
Mes</option>
<option value="1">
enero</option>
<option value="2">
febrero</option>
<option value="3">
marzo</option>
<option value="4">
abril</option>
<option value="5">
mayo</option>
<option value="6">
junio</option>
<option value="7" selected="selected">
julio</option>
<option value="8">
agosto</option>
<option value="9">
septiembre</option>
<option value="10">
octubre</option>
<option value="11">
noviembre</option>
<option value="12">
diciembre</option>
</select>
   <select name="entry.1705849412_day" disabled="disabled">
<option value="">
Día</option>
<option value="1">
1</option>
<option value="2">
2</option>
<option value="3">
3</option>
<option value="4">
4</option>
<option value="5">
5</option>
<option value="6">
6</option>
<option value="7">
7</option>
<option value="8">
8</option>
<option value="9">
9</option>
<option value="10">
10</option>
<option value="11">
11</option>
<option value="12">
12</option>
<option value="13">
13</option>
<option value="14">
14</option>
<option value="15">
15</option>
<option value="16">
16</option>
<option value="17">
17</option>
<option value="18">
18</option>
<option value="19">
19</option>
<option value="20">
20</option>
<option value="21">
21</option>
<option value="22">
22</option>
<option value="23">
23</option>
<option value="24">
24</option>
<option value="25">
25</option>
<option value="26" selected="selected">
26</option>
<option value="27">
27</option>
<option value="28">
28</option>
<option value="29">
29</option>
<option value="30">
30</option>
<option value="31">
31</option>
</select>
 
<select name="entry.1705849412_year" disabled="disabled">
<option value="">
Año</option>
<option value="1896">
1896</option>
<option value="1897">
1897</option>
<option value="1898">
1898</option>
<option value="1899">
1899</option>
<option value="1900">
1900</option>
<option value="1901">
1901</option>
<option value="1902">
1902</option>
<option value="1903">
1903</option>
<option value="1904">
1904</option>
<option value="1905">
1905</option>
<option value="1906">
1906</option>
<option value="1907">
1907</option>
<option value="1908">
1908</option>
<option value="1909">
1909</option>
<option value="1910">
1910</option>
<option value="1911">
1911</option>
<option value="1912">
1912</option>
<option value="1913">
1913</option>
<option value="1914">
1914</option>
<option value="1915">
1915</option>
<option value="1916">
1916</option>
<option value="1917">
1917</option>
<option value="1918">
1918</option>
<option value="1919">
1919</option>
<option value="1920">
1920</option>
<option value="1921">
1921</option>
<option value="1922">
1922</option>
<option value="1923">
1923</option>
<option value="1924">
1924</option>
<option value="1925">
1925</option>
<option value="1926">
1926</option>
<option value="1927">
1927</option>
<option value="1928">
1928</option>
<option value="1929">
1929</option>
<option value="1930">
1930</option>
<option value="1931">
1931</option>
<option value="1932">
1932</option>
<option value="1933">
1933</option>
<option value="1934">
1934</option>
<option value="1935">
1935</option>
<option value="1936">
1936</option>
<option value="1937">
1937</option>
<option value="1938">
1938</option>
<option value="1939">
1939</option>
<option value="1940">
1940</option>
<option value="1941">
1941</option>
<option value="1942">
1942</option>
<option value="1943">
1943</option>
<option value="1944">
1944</option>
<option value="1945">
1945</option>
<option value="1946">
1946</option>
<option value="1947">
1947</option>
<option value="1948">
1948</option>
<option value="1949">
1949</option>
<option value="1950">
1950</option>
<option value="1951">
1951</option>
<option value="1952">
1952</option>
<option value="1953">
1953</option>
<option value="1954">
1954</option>
<option value="1955">
1955</option>
<option value="1956">
1956</option>
<option value="1957">
1957</option>
<option value="1958">
1958</option>
<option value="1959">
1959</option>
<option value="1960">
1960</option>
<option value="1961">
1961</option>
<option value="1962">
1962</option>
<option value="1963">
1963</option>
<option value="1964">
1964</option>
<option value="1965">
1965</option>
<option value="1966">
1966</option>
<option value="1967">
1967</option>
<option value="1968">
1968</option>
<option value="1969">
1969</option>
<option value="1970">
1970</option>
<option value="1971">
1971</option>
<option value="1972">
1972</option>
<option value="1973">
1973</option>
<option value="1974">
1974</option>
<option value="1975">
1975</option>
<option value="1976">
1976</option>
<option value="1977">
1977</option>
<option value="1978">
1978</option>
<option value="1979">
1979</option>
<option value="1980">
1980</option>
<option value="1981">
1981</option>
<option value="1982">
1982</option>
<option value="1983">
1983</option>
<option value="1984">
1984</option>
<option value="1985">
1985</option>
<option value="1986">
1986</option>
<option value="1987">
1987</option>
<option value="1988">
1988</option>
<option value="1989">
1989</option>
<option value="1990">
1990</option>
<option value="1991">
1991</option>
<option value="1992">
1992</option>
<option value="1993">
1993</option>
<option value="1994">
1994</option>
<option value="1995">
1995</option>
<option value="1996">
1996</option>
<option value="1997">
1997</option>
<option value="1998">
1998</option>
<option value="1999">
1999</option>
<option value="2000">
2000</option>
<option value="2001">
2001</option>
<option value="2002">
2002</option>
<option value="2003">
2003</option>
<option value="2004">
2004</option>
<option value="2005">
2005</option>
<option value="2006">
2006</option>
<option value="2007">
2007</option>
<option value="2008">
2008</option>
<option value="2009">
2009</option>
<option value="2010">
2010</option>
<option value="2011">
2011</option>
<option value="2012">
2012</option>
<option value="2013">
2013</option>
<option value="2014">
2014</option>
<option value="2015">
2015</option>
<option value="2016">
2016</option>
<option value="2017">
2017</option>
<option value="2018">
2018</option>
<option value="2019" selected="selected">
2019</option>
<option value="2020">
2020</option>
<option value="2021">
2021</option>
<option value="2022">
2022</option>
<option value="2023">
2023</option>
<option value="2024">
2024</option>
<option value="2025">
2025</option>
<option value="2026">
2026</option>
<option value="2027">
2027</option>
<option value="2028">
2028</option>
<option value="2029">
2029</option>
<option value="2030">
2030</option>
<option value="2031">
2031</option>
<option value="2032">
2032</option>
<option value="2033">
2033</option>
<option value="2034">
2034</option>
<option value="2035">
2035</option>
<option value="2036">
2036</option>
<option value="2037">
2037</option>
<option value="2038">
2038</option>
<option value="2039">
2039</option>
<option value="2040">
2040</option>
<option value="2041">
2041</option>
<option value="2042">
2042</option>
<option value="2043">
2043</option>
<option value="2044">
2044</option>
<option value="2045">
2045</option>
<option value="2046">
2046</option>
<option value="2047">
2047</option>
<option value="2048">
2048</option>
<option value="2049">
2049</option>
<option value="2050">
2050</option>
<option value="2051">
2051</option>
<option value="2052">
2052</option>
<option value="2053">
2053</option>
<option value="2054">
2054</option>
<option value="2055">
2055</option>
<option value="2056">
2056</option>
<option value="2057">
2057</option>
<option value="2058">
2058</option>
<option value="2059">
2059</option>
<option value="2060">
2060</option>
<option value="2061">
2061</option>
<option value="2062">
2062</option>
<option value="2063">
2063</option>
<option value="2064">
2064</option>
<option value="2065">
2065</option>
<option value="2066">
2066</option>
<option value="2067">
2067</option>
<option value="2068">
2068</option>
<option value="2069">
2069</option>
</select>

</div>

</div>
</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0;font:inherit">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Hora de la Atención
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>
</label>


<div>
<div dir="ltr" style="border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
<select name="entry.206244955_hour" disabled="disabled">
<option value="">
h</option>
<option value="00">
00</option>
<option value="01">
01</option>
<option value="02">
02</option>
<option value="03">
03</option>
<option value="04">
04</option>
<option value="05">
05</option>
<option value="06">
06</option>
<option value="07">
07</option>
<option value="08">
08</option>
<option value="09">
09</option>
<option value="10" selected="selected">
10</option>
<option value="11">
11</option>
<option value="12">
12</option>
<option value="13">
13</option>
<option value="14">
14</option>
<option value="15">
15</option>
<option value="16">
16</option>
<option value="17">
17</option>
<option value="18">
18</option>
<option value="19">
19</option>
<option value="20">
20</option>
<option value="21">
21</option>
<option value="22">
22</option>
<option value="23">
23</option>
</select>

.
<select name="entry.206244955_minute" disabled="disabled">
<option value="">
min</option>
<option value="00">
00</option>
<option value="01">
01</option>
<option value="02">
02</option>
<option value="03">
03</option>
<option value="04">
04</option>
<option value="05">
05</option>
<option value="06">
06</option>
<option value="07">
07</option>
<option value="08">
08</option>
<option value="09">
09</option>
<option value="10" selected="selected">
10</option>
<option value="11">
11</option>
<option value="12">
12</option>
<option value="13">
13</option>
<option value="14">
14</option>
<option value="15">
15</option>
<option value="16">
16</option>
<option value="17">
17</option>
<option value="18">
18</option>
<option value="19">
19</option>
<option value="20">
20</option>
<option value="21">
21</option>
<option value="22">
22</option>
<option value="23">
23</option>
<option value="24">
24</option>
<option value="25">
25</option>
<option value="26">
26</option>
<option value="27">
27</option>
<option value="28">
28</option>
<option value="29">
29</option>
<option value="30">
30</option>
<option value="31">
31</option>
<option value="32">
32</option>
<option value="33">
33</option>
<option value="34">
34</option>
<option value="35">
35</option>
<option value="36">
36</option>
<option value="37">
37</option>
<option value="38">
38</option>
<option value="39">
39</option>
<option value="40">
40</option>
<option value="41">
41</option>
<option value="42">
42</option>
<option value="43">
43</option>
<option value="44">
44</option>
<option value="45">
45</option>
<option value="46">
46</option>
<option value="47">
47</option>
<option value="48">
48</option>
<option value="49">
49</option>
<option value="50">
50</option>
<option value="51">
51</option>
<option value="52">
52</option>
<option value="53">
53</option>
<option value="54">
54</option>
<option value="55">
55</option>
<option value="56">
56</option>
<option value="57">
57</option>
<option value="58">
58</option>
<option value="59">
59</option>
</select>



<div style="height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Performance Status ECOG del Paciente
<label>
</label>

<span style="color:#c43b1d">
*</span>
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>
</label>


<select name="entry.1747608258" disabled="disabled">
<option value="">
</option>
<option value="0" disabled="disabled">
0</option>
<option value="1" disabled="disabled" selected="selected">
1</option>
<option value="2" disabled="disabled">
2</option>
<option value="3" disabled="disabled">
3</option>
<option value="4" disabled="disabled">
4</option>
</select>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Escala Dolor EVA Actual
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>
</label>



<table border="0" cellpadding="5" cellspacing="0">
<tbody>
<tr>
<td style="text-align:center">
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
0</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
1</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
2</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
3</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
4</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
5</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
6</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
7</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
8</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
9</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
10</label>
</td>
<td style="text-align:center">
</td>
</tr>
<tr>
<td style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em;padding-left:0">
<div>
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" checked="checked" value="0" />
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</td>
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<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="1" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="2" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="3" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="4" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="5" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="6" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="7" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="8" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="9" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1421689035" disabled="disabled" value="10" />
</div>
</td>
<td style="text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em;padding-right:0">
</td>
</tr>
</tbody>
</table>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Escala Dolor EVA Máximo
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>
</label>



<table border="0" cellpadding="5" cellspacing="0">
<tbody>
<tr>
<td style="text-align:center">
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
0</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
1</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
2</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
3</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
4</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
5</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
6</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
7</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
8</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
9</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
10</label>
</td>
<td style="text-align:center">
</td>
</tr>
<tr>
<td style="text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em;padding-left:0">
<div>
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="0" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="1" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="2" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="3" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="4" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="5" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" checked="checked" value="6" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="7" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="8" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="9" />
</div>
</td>
<td style="text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em">
<div>
<input type="radio" name="entry.1244707512" disabled="disabled" value="10" />
</div>
</td>
<td style="text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:0.5em 0.25em;padding-right:0">
</td>
</tr>
</tbody>
</table>

</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<label>
<div style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Escala Dolor EVA Mínimo
</div>

<div dir="auto" style="display:block;margin:0.1em 0 0.25em 0;color:#666">
</div>
</label>



<table border="0" cellpadding="5" cellspacing="0">
<tbody>
<tr>
<td style="text-align:center">
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
0</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
1</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
2</label>
</td>
<td style="text-align:center">
<label style="display:block;padding:0.5em 0 0.5em">
3</label>
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*</span>
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Paciente consciente, lucida, orientada en tiempo espacio y persona, glasgow 15 pts. en buenas condiciones generales, P/A:116/71 mm/hg, FC: 88x&#39; Sat: 99%. T°:36.2°c .  Paciente con buen estado de ánimo refiere no haber presentado, nauseas, vomito ni deposiciones liquidas. Paciente ha presentado dolor, el cual cede con medicamentos indicados. Apetito aumentado refiere buena tolerancia a alimentos, ha podido dormir sin uso de medicamentos, continúa con caída de cabello de manera abundante e hiperpigmentacion a distal en dedos de ambas manos, dedos del pie y zona plantar de ambos pies, en pies se observa piel descamativa, sin sangramento ni calor local. Paciente refiere que se suspendió sesión de quimioterapia por bajo recuento de plaquetas, por lo cual ha presentado sangramento en encías y petequias en EEII.</div>



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Examen Físico
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Cabeza: normocraneo, simetrica, distribucion de cabello adecuado, cuero cabelludo sin lesiones, ni descamaciones, higiene conservada, cabello corto canoso, ondulado y delgado, refiere aumento de caída de cabello. • Oidos: simétricos, pabellon auricular sin lesiones ni secreciones. •Cara: simetrica, piel indemne y palida; cejas simétricas, parpadeo espontáneo; conjuntivas y lagrimal rosados e hidratados; esclera limpia, pupilas isocóricas, oscuras y fotorreactivas. • Boca: mucosas hidratadas, sin lesiones en orofaringe, no utiliza protesis dental. • Cuello: simétrico, movilidad conservada, sin dolor a la palpación, no se palpan ganglios, pulso carotideo presente. • EESS: movilidad conservada, piel palida e indemne pulsos radial y braquial presentes. se observa hiperpigmentacion e hipersensibilidad a distal de dedos en ambas manos • Tórax: simétrico, ruidos pulmonares presente, disminuido en base de pulmón derecho, no presenta lesiones en piel. • Abdomen: contorno simetrico, abdomen blando depresible indoloro, se palpa empastamiento en flaco derecho y mesogastrio. se observan heridas de 2 cm aprox cicatrizadas, por biopsia, RHA (&#43;) ligeramente aumentados • EEII: Pierna derecha e izquierda: movilidad conservada, piel indemne sin cicatrices ni heridas, pulsos popliteo, tibial y pedio (&#43;), sin edema, presenta remocion parcial de la uña de primer ortejo de ambos pies. se observa hiperpigmentacion y piel descamativa, hipersensibilidad y dolor a la palpación a distal de dedos y en zona plantar de ambos pies, se observan petequias en las ambas piernas a nivel de la rodilla• Genitales: femeninos • Diuresis: patron conservado • Deposiciones: patron conservado.</div>



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Cáncer Gástrico</div>



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se realiza educacion con respecto a: 
- adherencia a tto de hta, se educa sobre sintomas de alarma para acudir a urgencia 
- uso de medicacion para el dolor SOS</div>



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paracetamol 500mg c/8 hrs 
Tramadol 5 gts c/12 hrs  
viadil forte  20 gts c/8 hrs 
izofran 8mg 1comp sos 
cicaplast baume aplicar 2 veces al día en área afectada 
bariederm aplicar 3 veces al día en labios</div>



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Derivación a otro Prestador Domiciliario
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Sólo llene esta sección si es médico y solicita la visita de otro prestador del equipo</div>
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<label>
<span style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="disabled" value="KINESIOLOGO" />
</span>

KINESIOLOGO
</label>
</li>
<li style="margin:0;line-height:1.3em;padding-bottom:0.5em">

<label>
<span style="display:inline-block">
<input type="checkbox" name="entry.503039759" disabled="disabled" value="PSICOLOGO" />
</span>

PSICOLOGO
</label>
</li>
</ul>


</div>
</div>
</div>

<br />
 <div>

<div dir="auto" style="margin:12px 0;max-width:100%">
<div style="margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">

<h2 style="display:block;font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
</h2>

<div style="text-align:right">
<img src="https://lh5.googleusercontent.com/Bpur5zPteyG-bXtM-WNRuiLwTi8myvetX7lBkdjzbnQyqUlGcuv84zmWyU3x0Ua2-_WXX9PiJ2cMBOO0zhG2nHX7tXXPHH6_X8UTG8MZzIBwxETkF0a8JyZtuxSL" style="width:78px;outline:none" alt="Imagen sin título" />
</div>

</div>
</div>
</div>

<br />
</form>
</div>
</div>
</td>
</tr>
<tr>
</tr>
</tbody>
</table>
</div>
<table align="center" cellpadding="0" cellspacing="0" style="max-width:672px;min-width:154px" width="100%">
<tbody>
<tr>
<td>
</td>
</tr>
<tr>
<td>
<a href="https://docs.google.com/forms?usp&#61;mail_form_link" style="color:#424242;font-size:13px">
Crear tu propio Formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</blockquote>
</div>
<br>
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