<div dir=3D"ltr">
<br>
<br>
<div class=3D"gmail_quote">
<div dir=3D"ltr" class==3D"gmail_attr">
---------- Forwarded message ---------<br>
De: <strong class=3D"gmail_sendername" dir=3D"auto">
Formularios de Google</strong>
 <span dir=3D"auto">
&lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;</span>
<br>
Date: vie., 2 ago. 2019 a las 23:23<br>
Subject: visita paciente mario barrientos, 1 agosto 2019<br>
To:  &lt;<a href=3D"mailto:zomyzaldivarbatista@gmail.com">
zomyzaldivarbatista@gmail.com</a>
&gt;<br>
</div>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Formularios de Google" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff;border-bottom:1px solid #e0e0e0;margin:0 auto;max-width:624px;min-width:154px;padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Gracias por rellenar <a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target=3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"m_8945837417438993653ss-form-container">
<div class=3D"m_8945837417438993653ss-form-heading">
<h1 class=3D"m_8945837417438993653ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"m_8945837417438993653ss-form-desc m_8945837417438993653ss-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_8945837417438993653ss-form">
<form method=3D"GET" id=3D"m_8945837417438993653ss-form" target=3D"_blank">
<br>
<div class=3D"m_8945837417438993653ss-form-question m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-item-required m_8945837417438993653ss-text" style=3D"margin:12px 0">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8945837417438993653ss-q-item-label" for=3D"m_8945837417438993653emailAddress">
<div class=3D"m_8945837417438993653ss-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_8945837417438993653emailAddress">
</label>
<span class=3D"m_8945837417438993653ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"m_8945837417438993653ss-q-text m_8945837417438993653ss-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:zomyzaldivarbatista@gmail.com" target=3D"_blank">
zomyzaldivarbatista@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_8945837417438993653ss-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_8945837417438993653ss-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 leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_8945837417438993653ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"m_8945837417438993653ss-page-description m_8945837417438993653ss-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_8945837417438993653ss-form-question m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-item-required m_8945837417438993653ss-text" style=3D"margin:12px 0">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8945837417438993653ss-q-item-label" for=3D"m_8945837417438993653entry_579114469">
<div class=3D"m_8945837417438993653ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label for=3D"m_8945837417438993653itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8945837417438993653ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8945837417438993653ss-q-help m_8945837417438993653ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8945837417438993653ss-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%">
zomary zaldivar</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8945837417438993653ss-form-question m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-item-required m_8945837417438993653ss-text" style=3D"margin:12px 0">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8945837417438993653ss-q-item-label" for=3D"m_8945837417438993653entry_1276273985">
<div class=3D"m_8945837417438993653ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label for=3D"m_8945837417438993653itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8945837417438993653ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8945837417438993653ss-q-help m_8945837417438993653ss-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_8945837417438993653ss-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%">
25784794-2</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8945837417438993653ss-form-question m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-item-required m_8945837417438993653ss-select" style=3D"margin:12px 0">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8945837417438993653ss-q-item-label" for=3D"m_8945837417438993653entry_133691676">
<div class=3D"m_8945837417438993653ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label for=3D"m_8945837417438993653itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8945837417438993653ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8945837417438993653ss-q-help m_8945837417438993653ss-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_8945837417438993653entry_133691676">
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled selected>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div class=3D"m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_8945837417438993653ss-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_8945837417438993653ss-image" title=3D"" src=3D"https://lh3.googleusercontent.com/mRJInQVKRU12r9blREv2jmlzETLT9JfIHWC0FaeXYfPraPFE9ebBRX8P_hmpfiBP6BNpOgjPBYU0zwBxYxgoLvjQ7EjfjoRTJ2_-8flTaiU_wC008XC8LpcEJ_Yp" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_8945837417438993653ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"m_8945837417438993653ss-page-description m_8945837417438993653ss-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_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-section-header" style=3D"margin:12px 0">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_8945837417438993653ss-section-title" style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"m_8945837417438993653ss-section-description m_8945837417438993653ss-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_8945837417438993653ss-form-question m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-item-required m_8945837417438993653ss-text" style=3D"margin:12px 0">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8945837417438993653ss-q-item-label" for=3D"m_8945837417438993653entry_823811303">
<div class=3D"m_8945837417438993653ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label for=3D"m_8945837417438993653itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8945837417438993653ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8945837417438993653ss-q-help m_8945837417438993653ss-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_8945837417438993653ss-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%">
13967779-k</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8945837417438993653ss-form-question m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-item-required m_8945837417438993653ss-text" style=3D"margin:12px 0">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8945837417438993653ss-q-item-label" for=3D"m_8945837417438993653entry_1959365839">
<div class=3D"m_8945837417438993653ss-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_8945837417438993653itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8945837417438993653ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8945837417438993653ss-q-help m_8945837417438993653ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8945837417438993653ss-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%">
mario  barrientos</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8945837417438993653ss-form-question m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-item-required m_8945837417438993653ss-select" style=3D"margin:12px 0">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8945837417438993653ss-q-item-label" for=3D"m_8945837417438993653entry_545002227">
<div class=3D"m_8945837417438993653ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label for=3D"m_8945837417438993653itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8945837417438993653ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8945837417438993653ss-q-help m_8945837417438993653ss-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_8945837417438993653entry_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_8945837417438993653ss-form-question m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-item-required m_8945837417438993653ss-text" style=3D"margin:12px 0">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8945837417438993653ss-q-item-label" for=3D"m_8945837417438993653entry_1900161356">
<div class=3D"m_8945837417438993653ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label for=3D"m_8945837417438993653itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8945837417438993653ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8945837417438993653ss-q-help m_8945837417438993653ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8945837417438993653ss-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_8945837417438993653ss-form-question m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-item-required m_8945837417438993653ss-text" style=3D"margin:12px 0">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8945837417438993653ss-q-item-label" for=3D"m_8945837417438993653entry_1298871758">
<div class=3D"m_8945837417438993653ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label for=3D"m_8945837417438993653itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8945837417438993653ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8945837417438993653ss-q-help m_8945837417438993653ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8945837417438993653ss-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_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-embeddable-object-container" style=3D"margin:12px 0;max-width:100%">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_8945837417438993653ss-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_8945837417438993653ss-image" title=3D"" src=3D"https://lh6.googleusercontent.com/URytM0QWRGW_JEL0xQxvOLvwPRJIHyqlnKOm6ky9DRBfzvYVPaAngXV35GNHnaVG-dm9Orno4lr8sy8E-KB9tMrmIhFbVQiOPWy3vUclqRKAJ51dvLdhjBKgXdLO" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-page-break" style=3D"margin:12px 0">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 class=3D"m_8945837417438993653ss-page-title" style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3=B3n Domiciliaria</h2>
<div class=3D"m_8945837417438993653ss-page-description m_8945837417438993653ss-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_8945837417438993653ss-form-question m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-item-required m_8945837417438993653ss-radio" style=3D"margin:12px 0">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8945837417438993653ss-q-item-label" for=3D"m_8945837417438993653entry_2073233714">
<div class=3D"m_8945837417438993653ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label for=3D"m_8945837417438993653itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8945837417438993653ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8945837417438993653ss-q-help m_8945837417438993653ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul class=3D"m_8945837417438993653ss-choices" style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li class=3D"m_8945837417438993653ss-choice-item" style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span class=3D"m_8945837417438993653ss-choice-item-control m_8945837417438993653goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio" id=3D"m_8945837417438993653group_1222378237_1" class=3D"m_8945837417438993653ss-q-radio">
</span>
<span class=3D"m_8945837417438993653ss-choice-label">
Domicilio</span>
</label>
</li>
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<label>
<span class=3D"m_8945837417438993653ss-choice-item-control m_8945837417438993653goog-inline-block" style=3D"display:inline-block">
<input type==3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio" id=3D"m_8945837417438993653group_1222378237_2" class=3D"m_8945837417438993653ss-q-radio">
</span>
<span class=3D"m_8945837417438993653ss-choice-label">
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div class=3D"m_8945837417438993653ss-form-question m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-item-required m_8945837417438993653ss-date" style=3D"margin:12px 0">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8945837417438993653ss-q-item-label" for=3D"m_8945837417438993653entry_1705849412">
<div class=3D"m_8945837417438993653ss-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_8945837417438993653itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8945837417438993653ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8945837417438993653ss-q-help m_8945837417438993653ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8945837417438993653ss-q-date">
<div class=3D"m_8945837417438993653ss-datetime-box m_8945837417438993653goog-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"">
D=C3=ADa</option>
<option value=3D"1" selected>
1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
</select>
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<option value=3D"">
Mes</option>
<option value=3D"1">
enero</option>
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febrero</option>
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marzo</option>
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abril</option>
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mayo</option>
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junio</option>
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julio</option>
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agosto</option>
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septiembre</option>
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octubre</option>
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noviembre</option>
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diciembre</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled id=3D"m_8945837417438993653entry.1705849412_year">
<option value=3D"">
A=C3=B1o</option>
<option value=3D"1896">
1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1916</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
 <option value==3D"2000">
2000</option>
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2001</option>
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2002</option>
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2003</option>
 <option value==3D"2004">
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>
 <option value==3D"2018">
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>
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2041</option>
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2042</option>
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2043</option>
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2044</option>
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2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
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2048</option>
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2049</option>
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2050</option>
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2051</option>
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2052</option>
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2053</option>
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2054</option>
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2055</option>
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2056</option>
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2057</option>
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2058</option>
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2059</option>
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2060</option>
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2061</option>
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2062</option>
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2063</option>
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2064</option>
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2065</option>
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2066</option>
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2067</option>
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2068</option>
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2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8945837417438993653ss-form-question m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-item-required m_8945837417438993653ss-time" style=3D"margin:12px 0;font:inherit">
<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8945837417438993653ss-q-item-label" for=3D"m_8945837417438993653entry_206244955">
<div class=3D"m_8945837417438993653ss-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_8945837417438993653itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8945837417438993653ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"m_8945837417438993653ss-q-help m_8945837417438993653ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8945837417438993653ss-q-time">
<div class=3D"m_8945837417438993653ss-datetime-box m_8945837417438993653goog-inline-block" dir=3D"ltr" style=3D"border:1px solid #dcdcdc;margin-right:2em;min-height:32px;padding-left:3px;vertical-align:middle;margin:4px 3px;display:inline-block">
<select name=3D"entry.206244955_hour" disabled id=3D"m_8945837417438993653entry.206244955_hour">
<option value=3D"">
h</option>
<option value=3D"00">
00</option>
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01</option>
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02</option>
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03</option>
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04</option>
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05</option>
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06</option>
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07</option>
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08</option>
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09</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
</select>
:<select name=3D"entry.206244955_minute" disabled id=3D"m_8945837417438993653entry.206244955_minute">
<option value=3D"">
min</option>
<option value=3D"00">
00</option>
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01</option>
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02</option>
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03</option>
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04</option>
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09</option>
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10</option>
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11</option>
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12</option>
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13</option>
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14</option>
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15</option>
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16</option>
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17</option>
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18</option>
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19</option>
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20</option>
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21</option>
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22</option>
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23</option>
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24</option>
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25</option>
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26</option>
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27</option>
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28</option>
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29</option>
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30</option>
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31</option>
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32</option>
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33</option>
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34</option>
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35</option>
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36</option>
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37</option>
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38</option>
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39</option>
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40</option>
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41</option>
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<div class=3D"m_8945837417438993653ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label class=3D"m_8945837417438993653ss-q-item-label" for=3D"m_8945837417438993653entry_1716090865">
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Escala Dolor EVA Actual</div>
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<label class=3D"m_8945837417438993653ss-scalenumber" for=3D"m_8945837417438993653group_1421689035_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
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<label class=3D"m_8945837417438993653ss-scalenumber" for=3D"m_8945837417438993653group_1421689035_2" style=3D"display:block;padding:0.5em 0 .5em">
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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6</label>
</td>
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7</label>
</td>
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8</label>
</td>
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9</label>
</td>
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10</label>
</td>
<td class=3D"m_8945837417438993653ss-scalenumbers" style=3D"text-align:center">
</td>
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<br>
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<div class=3D"m_8945837417438993653ss-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_8945837417438993653ss-q-help m_8945837417438993653ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
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</td>
<td class=3D"m_8945837417438993653ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8945837417438993653ss-scalenumber" for=3D"m_8945837417438993653group_1244707512_1" style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td class=3D"m_8945837417438993653ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8945837417438993653ss-scalenumber" for=3D"m_8945837417438993653group_1244707512_2" style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
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<label class=3D"m_8945837417438993653ss-scalenumber" for=3D"m_8945837417438993653group_1244707512_3" style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td class=3D"m_8945837417438993653ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8945837417438993653ss-scalenumber" for=3D"m_8945837417438993653group_1244707512_4" style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td class=3D"m_8945837417438993653ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8945837417438993653ss-scalenumber" for=3D"m_8945837417438993653group_1244707512_5" style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
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<label class=3D"m_8945837417438993653ss-scalenumber" for=3D"m_8945837417438993653group_1244707512_6" style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label class=3D"m_8945837417438993653ss-scalenumber" for=3D"m_8945837417438993653group_1244707512_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td class=3D"m_8945837417438993653ss-scalenumbers" style=3D"text-align:center">
<label class=3D"m_8945837417438993653ss-scalenumber" for=3D"m_8945837417438993653group_1244707512_8" style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label class=3D"m_8945837417438993653ss-scalenumber" for=3D"m_8945837417438993653group_1244707512_9" style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label class=3D"m_8945837417438993653ss-scalenumber" for=3D"m_8945837417438993653group_1244707512_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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<label class=3D"m_8945837417438993653ss-scalenumber" for=3D"m_8945837417438993653group_1244707512_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_8945837417438993653ss-scalenumbers" style=3D"text-align:center">
</td>
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<tr>
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</td>
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Escala Dolor EVA M=C3=ADnimo</div>
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</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_8945837417438993653ss-scalenumber" for=3D"m_8945837417438993653group_853118630_7" style=3D"display:block;padding:0.5em 0 .5em">
6</label>
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7</label>
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8</label>
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<label class=3D"m_8945837417438993653ss-scalenumber" for=3D"m_8945837417438993653group_853118630_10" style=3D"display:block;padding:0.5em 0 .5em">
9</label>
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<label class=3D"m_8945837417438993653ss-scalenumber" for=3D"m_8945837417438993653group_853118630_11" style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td class=3D"m_8945837417438993653ss-scalenumbers" style=3D"text-align:center">
</td>
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Anamnesis/Evoluci=C3=B3n<label for=3D"m_8945837417438993653itemView.getDomIdToLabel()">
</label>
<span class=3D"m_8945837417438993653ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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Paciente masculino de 30 anos, diagnostico  Glioblastoma multiforme e IV tratado, en controles con neurocirujano en clinica universitaria. proximo control octubre con RMN. Se encuentra en control  nutricional con nutricionista por sobrepeso y dislipidemia y psicologa para terapia de contension, por estres por carga docente .  Se observa al paciente con buen estado general, familia y grupo de oncovida preocupados por comienzo de universidad en 2do semestre, que en el anterior sufrio de alce de TA por carga docente, manana se reanudan las clases. Niega sintomatologia. Manifiesta adherencia a cambio estilo de vida nutricional</div>
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<div class=3D"m_8945837417438993653ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen F=C3=ADsico<label for=3D"m_8945837417438993653itemView.getDomIdToLabel()">
</label>
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*</span>
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Paciente bien orientado TEP, cooperativo.    Sat 96%. EF: mucosas humedas y normocoloreadas. CV RR2T SRA TA 131/93  FC 68.  Rep: MV  sin estertores FR 16. cuello con peque=C3=B1a adenopatia cervical posterior de 0.5cm aprox en plano superficial. movible, dolorosa a la palpacion, impresiona inflamatoria. </div>
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Diagn=C3=B3stico<label for=3D"m_8945837417438993653itemView.getDomIdToLabel()">
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*</span>
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Glioblastoma multiforme e IV . Sobrepeso</div>
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Plan de Tratamiento e Indicaciones<label for=3D"m_8945837417438993653itemView.getDomIdToLabel()">
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<span class=3D"m_8945837417438993653ss-required-asterisk" style=3D"color:#c43b1d">
*</span>
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</div>
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Mantener regimen alimentario indicado por nutricionista. </div>
</div>
</div>
</div>
<br>
 <div class=3D"m_8945837417438993653ss-form-question m_8945837417438993653errorbox-good">
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<div class=3D"m_8945837417438993653ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div class=3D"m_8945837417438993653ss-q-help m_8945837417438993653ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
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no</div>
</div>
</div>
</div>
<br>
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<div class=3D"m_8945837417438993653ss-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_8945837417438993653ss-q-help m_8945837417438993653ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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D=C3=ADa</option>
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1</option>
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2</option>
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3</option>
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4</option>
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5</option>
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6</option>
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7</option>
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8</option>
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9</option>
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10</option>
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11</option>
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13</option>
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14</option>
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15</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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31</option>
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Mes</option>
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enero</option>
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febrero</option>
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marzo</option>
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abril</option>
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mayo</option>
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junio</option>
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julio</option>
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agosto</option>
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septiembre</option>
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A=C3=B1o</option>
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1896</option>
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1897</option>
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1898</option>
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1899</option>
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1900</option>
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1901</option>
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1902</option>
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1903</option>
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1904</option>
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1905</option>
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1906</option>
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1907</option>
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1908</option>
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1909</option>
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1910</option>
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1911</option>
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1912</option>
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1913</option>
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1914</option>
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1915</option>
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1917</option>
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1918</option>
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1919</option>
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1920</option>
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1921</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1948</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1965</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1976</option>
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1977</option>
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1978</option>
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1979</option>
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1980</option>
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1981</option>
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1982</option>
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1983</option>
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1984</option>
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1985</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
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2019</option>
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2020</option>
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2021</option>
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2022</option>
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2023</option>
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2024</option>
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2025</option>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
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2032</option>
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2033</option>
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2034</option>
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2035</option>
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2036</option>
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2037</option>
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2038</option>
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2039</option>
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2040</option>
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2041</option>
 <option value==3D"2042">
2042</option>
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2043</option>
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2044</option>
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2045</option>
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2046</option>
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2047</option>
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2048</option>
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2049</option>
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2050</option>
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2051</option>
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2052</option>
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2053</option>
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2054</option>
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2055</option>
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2056</option>
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2057</option>
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2058</option>
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2059</option>
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2060</option>
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2061</option>
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2062</option>
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2063</option>
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2064</option>
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2065</option>
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2066</option>
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2067</option>
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2068</option>
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2069</option>
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<br>
 <div class=3D"m_8945837417438993653ss-form-question m_8945837417438993653errorbox-good">
<div dir=3D"auto" class=3D"m_8945837417438993653ss-item m_8945837417438993653ss-text" style=3D"margin:12px 0">
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<div class=3D"m_8945837417438993653ss-q-title" style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"m_8945837417438993653ss-q-help m_8945837417438993653ss-secondary-text" dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div class=3D"m_8945837417438993653ss-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>
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</div>
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<br>
 <div class=3D"m_8945837417438993653ss-form-question m_8945837417438993653errorbox-good">
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Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"m_8945837417438993653ss-q-help m_8945837417438993653ss-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>
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ENFERMERA</span>
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<span class=3D"m_8945837417438993653ss-choice-label">
TENS</span>
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NUTRICIONISTA</span>
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<label>
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KINESIOLOGO</span>
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PSICOLOGO</span>
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<img class=3D"m_8945837417438993653ss-image" title=3D"" src=3D"https://lh5.googleusercontent.com/Bpur5zPteyG-bXtM-WNRuiLwTi8myvetX7lBkdjzbnQyqUlGcuv84zmWyU3x0Ua2-_WXX9PiJ2cMBOO0zhG2nHX7tXXPHH6_X8UTG8MZzIBwxETkF0a8JyZtuxSL" style=3D"width:78px;outline:none" alt=3D"Imagen sin leyenda">
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</table>
</div>
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" style=3D"max-width:672px;min-width:154px" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242;font-size:13px" target=3D"_blank">
Crea tu propio formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
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