<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">
<div>
<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">
<br>
</font>
<br>
</div>
</div>
</div>
</div>
</div>
</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: jue., 1 de ago. de 2019 a la(s) 21:30<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_3245466327944381722ss-form-container">
<div class=3D"m_3245466327944381722ss-form-heading">
<h1 class=3D"m_3245466327944381722ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_3245466327944381722ss-form-desc m_3245466327944381722ss-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_3245466327944381722ss-form">
<form method=3D"GET" id=3D"m_3245466327944381722ss-form" target=3D"_blank">
<br>
<div class=3D"m_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-item-required m_3245466327944381722ss-text" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722emailAddress">
<div class=3D"m_3245466327944381722ss-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_3245466327944381722emailAddress">
</label>
<span class=3D"m_3245466327944381722ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_3245466327944381722ss-q-text m_3245466327944381722ss-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_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_3245466327944381722ss-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_3245466327944381722ss-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_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_3245466327944381722ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_3245466327944381722ss-page-description m_3245466327944381722ss-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_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-item-required m_3245466327944381722ss-text" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_579114469">
<div class=3D"m_3245466327944381722ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_3245466327944381722itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3245466327944381722ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3245466327944381722ss-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 Sanchez</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-item-required m_3245466327944381722ss-text" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_1276273985">
<div class=3D"m_3245466327944381722ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_3245466327944381722itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3245466327944381722ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-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_3245466327944381722ss-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_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-item-required m_3245466327944381722ss-select" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_133691676">
<div class=3D"m_3245466327944381722ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_3245466327944381722itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3245466327944381722ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-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_3245466327944381722entry_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_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_3245466327944381722ss-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_3245466327944381722ss-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_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_3245466327944381722ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_3245466327944381722ss-page-description m_3245466327944381722ss-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_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_3245466327944381722ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_3245466327944381722ss-section-description m_3245466327944381722ss-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_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-item-required m_3245466327944381722ss-text" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_823811303">
<div class=3D"m_3245466327944381722ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_3245466327944381722itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3245466327944381722ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-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_3245466327944381722ss-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%">
11502419-1</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-item-required m_3245466327944381722ss-text" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_1959365839">
<div class=3D"m_3245466327944381722ss-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_3245466327944381722itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3245466327944381722ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3245466327944381722ss-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%">
Marlene Vargas</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-item-required m_3245466327944381722ss-select" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_545002227">
<div class=3D"m_3245466327944381722ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_3245466327944381722itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3245466327944381722ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-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_3245466327944381722entry_545002227">
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled>
COLMENA</option>
 <option value=3D"CONSALUD" disabled selected>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value=3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled>
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled>
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-item-required m_3245466327944381722ss-text" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_1900161356">
<div class=3D"m_3245466327944381722ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_3245466327944381722itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3245466327944381722ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3245466327944381722ss-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_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-item-required m_3245466327944381722ss-text" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_1298871758">
<div class=3D"m_3245466327944381722ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_3245466327944381722itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3245466327944381722ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3245466327944381722ss-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_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_3245466327944381722ss-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_3245466327944381722ss-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_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_3245466327944381722ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_3245466327944381722ss-page-description m_3245466327944381722ss-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_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-item-required m_3245466327944381722ss-radio" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_2073233714">
<div class=3D"m_3245466327944381722ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_3245466327944381722itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3245466327944381722ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_3245466327944381722ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_3245466327944381722ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_3245466327944381722ss-choice-item-control m_3245466327944381722goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_3245466327944381722group_1222378237_1" class=3D"m_3245466327944381722ss-q-radio">
</span>
<span class=3D"m_3245466327944381722ss-choice-label">
Domicilio</span>
</label>
</li>
 <li class=3D"m_3245466327944381722ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_3245466327944381722ss-choice-item-control m_3245466327944381722goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_3245466327944381722group_1222378237_2" class=3D"m_3245466327944381722ss-q-radio">
</span>
<span class=3D"m_3245466327944381722ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-item-required m_3245466327944381722ss-date" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_1705849412">
<div class=3D"m_3245466327944381722ss-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_3245466327944381722itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3245466327944381722ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3245466327944381722ss-q-date">
<div class=3D"m_3245466327944381722ss-datetime-box m_3245466327944381722goog-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_3245466327944381722ss-month-dropdown" id=3D"m_3245466327944381722entry.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_3245466327944381722ss-day-dropdown" id=3D"m_3245466327944381722entry.1705849412_day">
<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
 <option value=3D"2">
2</option>
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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>
 <option value=3D"29">
29</option>
 <option value=3D"30">
30</option>
 <option value=3D"31" selected>
31</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_3245466327944381722entry.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_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-item-required m_3245466327944381722ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_206244955">
<div class=3D"m_3245466327944381722ss-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_3245466327944381722itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3245466327944381722ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3245466327944381722ss-q-time">
<div class=3D"m_3245466327944381722ss-datetime-box m_3245466327944381722goog-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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06</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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.<select name=3D"entry.206244955_minute" disabled id=3D"m_3245466327944381722entry.206244955_minute">
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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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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>
 <option value=3D"37">
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_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-item-required m_3245466327944381722ss-select" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-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_3245466327944381722ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label for=3D"m_3245466327944381722itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3245466327944381722ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
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</option>
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0</option>
 <option value=3D"1" disabled selected>
1</option>
 <option value=3D"2" disabled>
2</option>
 <option value=3D"3" disabled>
3</option>
 <option value=3D"4" disabled>
4</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_1716090865">
<div class=3D"m_3245466327944381722ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-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_3245466327944381722entry_1421689035">
<tbody>
<tr>
<td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1421689035_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1421689035_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1421689035_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1421689035_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1421689035_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1421689035_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1421689035_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1421689035_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1421689035_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
</td>
</tr>
<tr>
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<div class=3D"m_3245466327944381722aria-todo">
</div>
</td>
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</div>
</td>
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</div>
</td>
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</div>
</td>
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</div>
</td>
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<div class=3D"m_3245466327944381722ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4" id=3D"m_3245466327944381722group_1421689035_5" class=3D"m_3245466327944381722ss-q-radio">
</div>
</td>
 <td class=3D"m_3245466327944381722ss-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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<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5" id=3D"m_3245466327944381722group_1421689035_6" class=3D"m_3245466327944381722ss-q-radio">
</div>
</td>
 <td class=3D"m_3245466327944381722ss-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_3245466327944381722ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6" id=3D"m_3245466327944381722group_1421689035_7" class=3D"m_3245466327944381722ss-q-radio">
</div>
</td>
 <td class=3D"m_3245466327944381722ss-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>
</td>
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<div class=3D"m_3245466327944381722ss-scalerow-fieldcell">
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9" id=3D"m_3245466327944381722group_1421689035_10" class=3D"m_3245466327944381722ss-q-radio">
</div>
</td>
 <td class=3D"m_3245466327944381722ss-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_3245466327944381722ss-scalerow-fieldcell">
<input type=3D"radio" name==3D"entry.1421689035" disabled value=3D"10" id=3D"m_3245466327944381722group_1421689035_11" class=3D"m_3245466327944381722ss-q-radio">
</div>
</td>
<td class=3D"m_3245466327944381722ss-scalerow m_3245466327944381722ss-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_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-scale" style=3D"margin:12px 0;overflow-x:auto">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_2064050596">
<div class=3D"m_3245466327944381722ss-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_3245466327944381722ss-q-help m_3245466327944381722ss-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_3245466327944381722entry_1244707512">
<tbody>
<tr>
<td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
</td>
<td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td class=3D"m_3245466327944381722ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
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<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
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</td>
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<div class=3D"m_3245466327944381722aria-todo">
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Escala Dolor EVA M=C3=ADnimo</div>
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0</label>
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1</label>
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2</label>
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3</label>
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4</label>
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5</label>
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<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_853118630_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
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<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_853118630_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
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8</label>
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<label class=3D"m_3245466327944381722ss-scalenumber" for=3D"m_3245466327944381722group_853118630_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
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10</label>
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</td>
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Visita se realiza en conjunto con la Dra. zomary y nutricionista Astrid.Usuaria en buenas condiciones generales, orientada en tiempo y espacio, sin dolor ni molestias. Refiere que el dolor de pelvis y columna cedi=C3=B3 desde el domingo, no tiene dificultades para movilizarse. No ha presentado sintomas vertiginosos.Si presenta dermatitis de contacto en ambas mamas, mayor en mama izquierda, con prurito. Refiere que ha pasado en otras oportunidades y ha tenido que recurrir al dermatologo.En periodo de quimioterapia con capecitabina.Alimentaci=C3=B3n bien tolerada por boca variada en cambios con nutricionista, refiere menor distensi=C3=B3n abdominal.Eliminaci=C3=B3n diuresis (+) deposiciones (+) en ba=C3=B1o.Patr=C3=B3n del sue=C3=B1o con ayuda farmacol=C3=B3gica.Actividades de la vida diaria sin complicaciones, evita actividades que requieran de alg=C3=BAn esfuerzo f=C3=ADsico.</div>
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*</span>
</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3245466327944381722ss-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%">
Piel y mucosas hidratadas..Palmas de manos y plantas de los pies secas.Abdomen blando depresible indoloro.Dermatitis en ambas mamas mayor en la derecha.Presion: 111/68Pulso: 90</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-item-required m_3245466327944381722ss-text" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_1690694733">
<div class=3D"m_3245466327944381722ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label for=3D"m_3245466327944381722itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3245466327944381722ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3245466327944381722ss-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 mamas</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-item-required m_3245466327944381722ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_1255665248">
<div class=3D"m_3245466327944381722ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label for=3D"m_3245466327944381722itemView.getDomIdToLabel()">
</label>
<span class=3D"m_3245466327944381722ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3245466327944381722ss-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%">
Seguir indicaciones medicas del tratamiento dermatitis.Evitar prendas que aumenten la dermatitisEvitar productos irritantes en la zona.Valorar dolor y caracteristicasHumectar pielSeguir alimentacion segun indicacion de nutricionista.En caso de persistir sintomas de dermatitis o algun cuadro agudo avisar.</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-paragraph-text" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_1648939075">
<div class=3D"m_3245466327944381722ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3245466327944381722ss-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_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-date" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_2063615873">
<div class=3D"m_3245466327944381722ss-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_3245466327944381722ss-q-help m_3245466327944381722ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3245466327944381722ss-q-date">
<div class=3D"m_3245466327944381722ss-datetime-box m_3245466327944381722goog-inline-block" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
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<option value=3D"">
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>
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diciembre</option>
</select>
   <select name=3D"entry.2063615873_day" disabled class=3D"m_3245466327944381722ss-day-dropdown" id=3D"m_3245466327944381722entry.2063615873_day">
<option value=3D"">
D=C3=ADa</option>
<option value=3D"1">
1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
 <option value=3D"16">
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value==3D"19">
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>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
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28</option>
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29</option>
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30</option>
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31</option>
</select>
=20<select name=3D"entry.2063615873_year" disabled id=3D"m_3245466327944381722entry.2063615873_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
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1897</option>
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1898</option>
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1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
 <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>
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1938</option>
 <option value=3D"1939">
1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
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1948</option>
 <option value=3D"1949">
1949</option>
 <option value==3D"1950">
1950</option>
 <option value=3D"1951">
1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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1979</option>
 <option value==3D"1980">
1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
 <option value==3D"2000">
2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
 <option value=3D"2019" selected>
2019</option>
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2020</option>
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2021</option>
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2022</option>
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2023</option>
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2024</option>
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2025</option>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
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2032</option>
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2033</option>
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2034</option>
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2035</option>
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2036</option>
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2037</option>
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2038</option>
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2039</option>
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2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <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_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-text" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_74766472">
<div class=3D"m_3245466327944381722ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_3245466327944381722ss-q-help m_3245466327944381722ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_3245466327944381722ss-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_3245466327944381722ss-form-question m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-checkbox" style=3D"margin:12px 0">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_3245466327944381722ss-q-item-label" for=3D"m_3245466327944381722entry_1219705969">
<div class=3D"m_3245466327944381722ss-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_3245466327944381722ss-q-help m_3245466327944381722ss-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_3245466327944381722ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_3245466327944381722ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_3245466327944381722ss-choice-item-control m_3245466327944381722goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"ENFERMERA" id=3D"m_3245466327944381722group_503039759_1" class=3D"m_3245466327944381722ss-q-checkbox">
</span>
<span class=3D"m_3245466327944381722ss-choice-label">
ENFERMERA</span>
</label>
</li>
 <li class=3D"m_3245466327944381722ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_3245466327944381722ss-choice-item-control m_3245466327944381722goog-inline-block" style=3D"display:inline-block">
<input type==3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"m_3245466327944381722group_503039759_2" class=3D"m_3245466327944381722ss-q-checkbox">
</span>
<span class=3D"m_3245466327944381722ss-choice-label">
TENS</span>
</label>
</li>
 <li class=3D"m_3245466327944381722ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_3245466327944381722ss-choice-item-control m_3245466327944381722goog-inline-block" style=3D"display:inline-block">
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<span class=3D"m_3245466327944381722ss-choice-label">
NUTRICIONISTA</span>
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</span>
<span class=3D"m_3245466327944381722ss-choice-label">
KINESIOLOGO</span>
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 <li class=3D"m_3245466327944381722ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
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<span class=3D"m_3245466327944381722ss-choice-label">
PSICOLOGO</span>
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<br>
 <div class=3D"m_3245466327944381722errorbox-good">
<div dir=3D"auto" class=3D"m_3245466327944381722ss-item m_3245466327944381722ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_3245466327944381722ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
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<img class=3D"m_3245466327944381722ss-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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</form>
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<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"max-width:672px;min-width:154px" width=3D"100%">
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<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242;font-size:13px" target=3D"_blank">
Crear tu propio Formulario de Google</a>
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