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Dispensary_HTN-DM_Form.html
5357 lines (5176 loc) · 275 KB
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Dispensary_HTN-DM_Form.html
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<html>
<head>
<meta name="viewport" content="width=device-width, initial-scale=1">
<link href="css/bootstrap.min.css" rel="stylesheet">
<link href="css/muzima.css" rel="stylesheet">
<link href="css/ui-darkness/jquery-ui-1.10.4.custom.min.css" rel="stylesheet">
<script src="js/jquery.min.js"></script>
<script src="js/jquery-ui-1.10.4.custom.min.js"></script>
<script src="js/jquery.validate.min.js"></script>
<script src="js/additional-methods.min.js"></script>
<script src="js/muzima.js"></script>
<title>Dispensary Form</title>
<style>
</style>
</head>
<body class="col-md-10 col-md-offset-1">
<div id="pre_populate_data"></div>
<form id="dispensary_form" name="dispensary_form">
<input type="hidden" name="reminder1.log" id="reminder1.log">
<input type="hidden" name="reminder2.log" id="reminder2.log">
<input type="hidden" name="reminder3.log" id="reminder3.log">
<input type="hidden" name="reminder4.log" id="reminder4.log">
<input type="hidden" name="reminder5.log" id="reminder5.log">
<input type="hidden" name="reminder6.log" id="reminder6.log">
<input type="hidden" name="reminder7.log" id="reminder7.log">
<input type="hidden" name="reminder8.log" id="reminder8.log">
<input type="hidden" name="reminder9.log" id="reminder9.log">
<input type="hidden" name="other_reminder.log" id="other_reminder.log">
<h2 class="text-center">CDM Dispensary HTN-DM Encounter Form V0.01</h2>
<div class="section">
<h3>Demographics</h3>
<div class="form-group">
<input class="form-control" id="patient.uuid"
name="patient.uuid" type="hidden" readonly="readonly">
</div>
<div class="form-group">
<label for="patient.medical_record_number">AMRS ID Number:</label>
<input class="form-control" id="patient.medical_record_number"
name="patient.medical_record_number" type="text" readonly="readonly">
</div>
<div class="form-group">
<label for="patient.family_name">Family Name:</label>
<input class="form-control" id="patient.family_name" name="patient.family_name" type="text"
readonly="readonly">
</div>
<div class="form-group">
<label for="patient.given_name">Given Name:</label>
<input class="form-control" id="patient.given_name" name="patient.given_name" type="text"
readonly="readonly">
</div>
<div class="form-group">
<label for="patient.middle_name">Middle Name:</label>
<input class="form-control" id="patient.middle_name" name="patient.middle_name" type="text"
readonly="readonly">
</div>
<div class="form-group">
<label for="patient.sex">Gender:</label>
<select class="form-control" id="patient.sex" name="patient.sex" disabled="disabled">
<option value="">...</option>
<option selected value="M">Male</option>
<option value="F">Female</option>
</select>
</div>
<div class="form-group">
<label for="patient.birth_date">Date Of Birth:</label>
<input class="form-control" id="patient.birth_date" name="patient.birth_date" type="text"
readonly="readonly" value="01-01-1972">
</div>
</div>
<div class="section">
<h3>Encounter Details</h3>
<div class="form-group">
<label for="encounter.location_id">Name of Dispensary:<span class="required">*</span></label>
<input class="form-control valid-location-only" id="encounter.location_id" type="text"
placeholder="Start typing something..." required="required">
<input class="form-control" name="encounter.location_id" type="hidden">
</div>
<div class="form-group">
<label for="encounter.provider_id_select">Provider Name:<span class="required">*</span></label>
<input class="form-control valid-provider-only" id="encounter.provider_id_select"
type="text" placeholder="Start typing something...">
<input class="form-control" name="encounter.provider_id_select" type="hidden">
</div>
<div class="form-group show_provider_id_text">
<label for="encounter.provider_id">Provider system-id:<span class="required">*</span></label>
<input class="form-control checkDigit" id="encounter.provider_id" disabled name="encounter.provider_id"
type="text" required="required" placeholder="Provider Id">
</div>
<div class="form-group">
<label for="encounter.encounter_datetime">Encounter Date:<span class="required">*</span></label>
<input class="form-control datepicker nonFutureDate past-date" id="encounter.encounter_datetime"
name="encounter.encounter_datetime" type="text" readonly="readonly"
required="required">
</div>
<div>
</div>
<div class="form-group">
<input class="form-control" id="encounter.form_uuid" name="encounter.form_uuid"
type="hidden" required="required">
</div>
<div class="form-group">
<label for="obs.current_visit_type">Visit Type:<span class="required">*</span></label>
<select class="form-control" id="obs.current_visit_type" name="obs.current_visit_type"
data-concept="1839^CURRENT VISIT TYPE^99DCT" required="required">
<option value="">...</option>
<option value="9456^FIRST DISPENSARY VISIT AFTER SCREENING^99DCT">
First dispensary visit after screening
</option>
<option value="9457^SECOND DISPENSARY VISIT AFTER SCREENING^99DCT">
Second dispensary visit after screening
</option>
<option value="7036^RETURN DISPENSARY VISIT^99DCT">Return dispensary visit</option>
<option value="7037^REFERRED FROM CLINIC^99DCT">Referred from clinic</option>
<option value="7875^WALK IN^99DCT">Walk-in</option>
</select>
</div>
</div>
<div id="main_observations_section">
<div class="section">
<h3>Health Insurance</h3>
<div class="form-group">
<label for="obs.has_nhif">Do you have NHIF?<span class="required">*</span></label>
<select class="form-control" id="obs.has_nhif" name="obs.has_nhif"
data-concept="6266^HEALTH INSURANCE^99DCT" required="required">
<option value="">...</option>
<option value="6815^KENYA NATIONAL HEALTH INSURANCE FUND^99DCT">
Yes
</option>
<option value="1066^NO^99DCT">
No
</option>
</select>
</div>
</div>
<div class="section">
<h3>Status of patient</h3>
<div class="form-group concept-set" data-concept="9168^TYPE OF FOLLOW-UP,DETAILED^99DCT">
<div class="form-group">
<label for="obs.patient_followup_for">
Patient being followed up for:
</label>
<div class="form-group">
<label class="font-normal">
<input id="obs.patient_followup_for.htn" type="checkbox" name="obs.patient_followup_for"
data-concept="2332^TYPE OF FOLLOW-UP^99DCT" value="903^HYPERTENSION^99DCT">
HTN
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.patient_followup_for.dm" type="checkbox" name="obs.patient_followup_for"
data-concept="2332^TYPE OF FOLLOW-UP^99DCT" value="175^DIABETES MELLITUS^99DCT">
DM
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.patient_followup_for.other" type="checkbox" name="obs.patient_followup_for"
data-concept="2332^TYPE OF FOLLOW-UP^99DCT" value="5622^OTHER NON-CODED^99DCT">
Other
</label>
</div>
</div>
<div class="form-group sub-section" id="patient_followup_for_other_value">
<label class="font-normal" for="obs.complaints_other_value">
Specify other follow up:<span class="required">*</span>
</label>
<input class="form-control" id="obs.complaints_other_value" type="text" required="required"
name="obs.complaints_other_value" data-concept="1915^FREETEXT GENERAL^99DCT">
</div>
</div>
<div class="sub-section" id="patient_status_hypertension">
<div class="form-group">
<label for="obs.patient_status_hypertension">
Hypertension status
</label>
<select class="form-control" id="obs.patient_status_hypertension"
name="obs.patient_status_hypertension"
data-concept="7288^HYPERTENSION STATUS^99DCT">
<option value="">...</option>
<option value="7285^NEW HYPERTENSIVE PATIENT^99DCT">New HTN Patient</option>
<option value="7286^KNOWN HYPERTENSIVE PATIENT^99DCT">Known HTN Patient</option>
</select>
</div>
<div class="form-group" id="patient_status_hypertension_diagnosis_year">
<label for="obs.patient_status_hypertension_diagnosis_year" class="font-normal">
Year of Diagnosis [Hypertension]:<span class="required">*</span></label>
<input class="form-control" id="obs.patient_status_hypertension_diagnosis_year"
name="obs.patient_status_hypertension_diagnosis_year" type="number"
placeholder="Enter year of Hypertension diagnosis"
data-concept="7284^YEAR OF DIAGNOSIS, HYPERTENSION^99DCT"
required="required">
</div>
</div>
<div class="sub-section" id="patient_status_diabetes">
<div class="form-group">
<label for="obs.patient_status_diabetes">
Diabetes status
</label>
<select class="form-control" id="obs.patient_status_diabetes"
name="obs.patient_status_diabetes"
data-concept="7287^DIABETES STATUS^99DCT">
<option value="">...</option>
<option value="7281^NEW DIABETIC PATIENT^99DCT">New DM Patient</option>
<option value="7282^KNOWN DIABETIC PATIENT^99DCT">Known DM Patient</option>
</select>
</div>
<div class="form-group" id="patient_status_diabetes_diagnosis_year">
<label for="obs.patient_status_diabetes_diagnosis_year" class="font-normal">
Year of Diagnosis [Diabetes]:<span class="required">*</span></label>
<input class="form-control" id="obs.patient_status_diabetes_diagnosis_year"
name="obs.patient_status_diabetes_diagnosis_year" type="number"
placeholder="Enter year of Diabetes diagnosis"
data-concept="7283^YEAR OF DIAGNOSIS, DIABETES^99DCT"
required="required">
</div>
<label class="alert alert-info new_dm_reminder">Do fasting blood sugar </label>
</div>
</div>
<div class="section">
<h3>Vital Signs</h3>
<div class="form-group">
<label for="obs.systolic_blood_pressure">Systolic Blood Pressure (mmHg):<span class="required">*</span></label>
<input class="form-control systolicBloodPressure" id="obs.systolic_blood_pressure"
name="obs.systolic_blood_pressure" type="number"
placeholder="Please record today's SBP" data-concept="5085^SYSTOLIC BLOOD PRESSURE^99DCT"
required="required">
</div>
<div class="form-group">
<label for="obs.diastolic_blood_pressure">Diastolic Blood Pressure (mmHg):<span
class="required">*</span></label>
<input class="form-control diastolicBloodPressure lessThankSystolic" id="obs.diastolic_blood_pressure"
name="obs.diastolic_blood_pressure" type="number"
placeholder="Please record today's DBP" data-concept="5086^DIASTOLIC BLOOD PRESSURE^99DCT"
required="required">
</div>
<div class="form-group">
<label for="pulse">Pulse Rate (per minute):</label>
<input class="form-control" id="pulse" name="pulse" type="number" placeholder="Please record today's pulse"
data-concept="5087^PULSE^99DCT">
</div>
<div class="form-group">
<label for="temperature_c">Temperature (centigrade):</label>
<input class="form-control" id="temperature_c" name="temperature_c" type="number"
placeholder="Please record today's temperature"
data-concept="5088^TEMPERATURE (C)^99DCT">
</div>
<div class="form-group">
<label for="weight_kg">Weight (KG):</label>
<input class="form-control" id="weight_kg" name="weight_kg" type="number"
placeholder="Please record today's weight"
data-concept="5089^WEIGHT (KG)^99DCT">
</div>
<div class="form-group">
<label for="height_cm">Height (CM):</label>
<input class="form-control" id="height_cm" name="height_cm" type="number"
placeholder="Please record today's height"
data-concept="5090^HEIGHT (CM)^99DCT">
</div>
<div class="form-group bodyMassIndex">
<label for="obs.body_mass_index">BMI:</label>
<input class="form-control" id="obs.body_mass_index" name="obs.body_mass_index"
type="number" readonly="readonly"
data-concept="1342^BODY MASS INDEX^99DCT">
</div>
<label class="alert alert-info" id="bmiReminder_underweight">
<b>Confirmed underweight</b>
</label>
<label class="alert alert-info" id="bmiReminder_overweight">
<b>Confirmed overweight</b>
<ul>
<li>Educate on weight reduction.</li>
</ul>
</label>
<div class="form-group menstrualPeriod">
<label for="obs.last_menstrual_period_qualitative">
How long ago was the first day of your menstrual period? <span class="required lmp_required_marker">*</span>
</label>
<input class="form-control datepicker past-date nonFutureDate"
id="obs.last_menstrual_period_qualitative"
name="obs.last_menstrual_period_qualitative"
data-concept="1836^LAST MENSTRUAL PERIOD DATE^99DCT"
readonly="readonly">
</select>
</div>
<label class="alert alert-info" id="lmp_reminder">
<b>Consider pregnancy test</b>
</label>
</div>
<div class="section">
<h3>Lab tests</h3>
<div class="form-group">
<label class="font-normal" for="tmp.labs_urinalysis">
<input type="checkbox" name="tmp.labs" id="tmp.labs_urinalysis"> Urinalysis
</label>
</div>
<div class="section" id="labs_urinalysis">
<div class="form-group">
<label>URINALYSIS</label>
</div>
<div class="form-group">
<label for="labs_urinalysis.result">Urinalysis Result:<span class="required">*</span></label>
<select class="form-control" id="labs_urinalysis.result" name="tmp.urinalysis_result" required="required">
<option value=""> ...</option>
<option value="Normal"> Normal</option>
<option value="Abnormal"> Abnormal</option>
<option value="Not Done"> Not Done</option>
</select>
</div>
<div class="sub-section" id="urinalysis_test_results">
<div class="concept-set" data-Concept="302^URINALYSIS^99DCT">
<div class="form-group">
<label>Protein:<span class="required">*</span></label>
<fieldset id="obs.urinalysis_result_protein" class="urinalysis_result">
<label class="font-normal">
<input id="protein_nil" class="urinalysis_result_nil" type="radio"
data-concept="2339^PRESENCE OF PROTEIN, URINE^99DCT"
name="obs.urinalysis_result_protein" required="required" value="664^NEGATIVE^99DCT"> Nil
</label>
<label class="font-normal">
<input id="protein_positive" class="urinalysis_result_positive" type="radio"
data-concept="2339^PRESENCE OF PROTEIN, URINE^99DCT"
name="obs.urinalysis_result_protein" required="required" value="703^POSITIVE^99DCT"> +
</label>
<label class="font-normal">
<input id="protein_strong_positive" class="urinalysis_result_strong_positive"
type="radio" data-concept="2339^PRESENCE OF PROTEIN, URINE^99DCT"
name="obs.urinalysis_result_protein" required="required" value="2074^STRONG POSITIVE^99DCT"> ++
</label>
<label class="font-normal">
<input id="protein_stronger_positive" class="urinalysis_result_stronger_positive"
type="radio" data-concept="2339^PRESENCE OF PROTEIN, URINE^99DCT"
name="obs.urinalysis_result_protein" required="required" value="2075^STRONGER POSITIVE^99DCT"> +++
</label>
</fieldset>
</div>
<div>
<input class="urinalysis_result_date_collected"
id="obs_datetime.urinalysis_result_protein_date_collected"
name="obs_datetime.urinalysis_result_protein_date_collected" type="hidden"
data-obsdatetimefor="obs.urinalysis_result_protein" readonly="readonly">
</div>
<div class="form-group">
<label>Leucocytes:<span class="required">*</span></label>
<fieldset id="obs.urinalysis_result_leucocytes" class="urinalysis_result">
<label class="font-normal">
<input id="leucocytes_nil" class="urinalysis_result_nil" type="radio"
name="obs.urinalysis_result_leucocytes" required="required" value="664^NEGATIVE^99DCT"
data-concept="6337^PRESENCE OF LEUKOCYTES^99DCT"> Nil
</label>
<label class="font-normal">
<input id="leucocytes_positive" type="radio" class="urinalysis_result_positive"
name="obs.urinalysis_result_leucocytes" required="required" value="703^POSITIVE^99DCT"
data-concept="6337^PRESENCE OF LEUKOCYTES^99DCT"> +
</label>
<label class="font-normal">
<input id="leucocytes_strong_positive" type="radio" class="urinalysis_result_strong_positive"
name="obs.urinalysis_result_leucocytes" required="required" value="2074^STRONG POSITIVE^99DCT"
data-concept="6337^PRESENCE OF LEUKOCYTES^99DCT"> ++
</label>
<label class="font-normal">
<input id="leucocytes_stronger_positive" type="radio" class="urinalysis_result_stronger_positive"
name="obs.urinalysis_result_leucocytes" required="required" value="2075^STRONGER POSITIVE^99DCT"
data-concept="6337^PRESENCE OF LEUKOCYTES^99DCT"> +++
</label>
</fieldset>
</div>
<div class="form-group">
<input class="form-control urinalysis_result_date_collected"
id="obs_datetime.urinalysis_result_leucocytes_date_collected"
name="obs_datetime.urinalysis_result_leucocytes_date_collected" type="hidden" required="required"
data-obsdatetimefor="obs.urinalysis_result_leucocytes" readonly="readonly">
</div>
<div class="form-group">
<label>Ketones:<span class="required">*</span></label>
<fieldset id="obs.urinalysis_result_ketones" class="urinalysis_result">
<label class="font-normal">
<input id="ketones_nil" class="urinalysis_result_nil" type="radio"
name="obs.urinalysis_result_ketones" required="required" value="664^NEGATIVE^99DCT"
data-concept="7276^PRESENCE OF KETONE, URINE^99DCT"> Nil
</label>
<label class="font-normal">
<input id="protein_positive" type="radio" class="urinalysis_result_positive"
name="obs.urinalysis_result_ketones" required="required" value="703^POSITIVE^99DCT"
data-concept="7276^PRESENCE OF KETONE, URINE^99DCT"> +
</label>
<label class="font-normal">
<input id="protein_strong_positive" type="radio" class="urinalysis_result_strong_positive"
name="obs.urinalysis_result_ketones" required="required" value="2074^STRONG POSITIVE^99DCT"
data-concept="7276^PRESENCE OF KETONE, URINE^99DCT"> ++
</label>
<label class="font-normal">
<input id="protein_stronger_positive" type="radio" class="urinalysis_result_stronger_positive"
name="obs.urinalysis_result_ketones" required="required" value="2075^STRONGER POSITIVE^99DCT"
data-concept="7276^PRESENCE OF KETONE, URINE^99DCT"> +++
</label>
</fieldset>
</div>
<div class="form-group">
<input class="form-control urinalysis_result_date_collected" id="obs_datetime.urinalysis_result_ketones_date_collected"
name="obs_datetime.urinalysis_result_ketones_date_collected" type="hidden" required="required"
data-obsdatetimefor="obs.urinalysis_result_ketones" readonly="readonly">
</div>
<div class="form-group">
<label>Glucose:<span class="required">*</span></label>
<fieldset id="obs.urinalysis_result_glucose" class="urinalysis_result">
<label class="font-normal">
<input id="glucose_nil" class="urinalysis_result_nil" type="radio" data-concept="2340^PRESENCE OF SUGAR, URINE^99DCT"
name="obs.urinalysis_result_glucose" required="required" value="664^NEGATIVE^99DCT"> Nil
</label>
<label class="font-normal">
<input id="glucose_positive" type="radio" class="urinalysis_result_positive"
data-concept="2340^PRESENCE OF SUGAR, URINE^99DCT"
name="obs.urinalysis_result_glucose" required="required" value="703^POSITIVE^99DCT"> +
</label>
<label class="font-normal">
<input id="glucose_strong_positive" type="radio" class="urinalysis_result_strong_positive"
data-concept="2340^PRESENCE OF SUGAR, URINE^99DCT"
name="obs.urinalysis_result_glucose" required="required" value="2074^STRONG POSITIVE^99DCT"> ++
</label>
<label class="font-normal">
<input id="glucose_stronger_positive" type="radio" class="urinalysis_result_stronger_positive"
data-concept="2340^PRESENCE OF SUGAR, URINE^99DCT"
name="obs.urinalysis_result_glucose" required="required" value="2075^STRONGER POSITIVE^99DCT"> +++
</label>
</fieldset>
</div>
<div class="form-group">
<input class="form-control urinalysis_result_date_collected" id="obs_datetime.urinalysis_result_glucose_date_collected"
name="obs_datetime.urinalysis_result_glucose_date_collected" type="hidden" required="required"
data-obsdatetimefor="obs.urinalysis_result_glucose" readonly="readonly">
</div>
<div class="form-group">
<label for="obs.urinalysis_result">Nitrites:<span class="required">*</span></label>
<fieldset id="obs.urinalysis_result_nitrites" class="urinalysis_result">
<label class="font-normal">
<input id="nitrites_nil" class="urinalysis_result_nil" type="radio"
data-concept="9307^PRESENCE OF NITRITES, URINE^99DCT"
name="obs.urinalysis_result_nitrites" required="required" value="664^NEGATIVE^99DCT"> Nil
</label>
<label class="font-normal">
<input id="nitrines_positive" type="radio" class="urinalysis_result_positive"
data-concept="9307^PRESENCE OF NITRITES, URINE^99DCT"
name="obs.urinalysis_result_nitrites" required="required" value="703^POSITIVE^99DCT"> +
</label>
<label class="font-normal">
<input id="nitrites_strong_positive" type="radio" class="urinalysis_result_strong_positive"
data-concept="9307^PRESENCE OF NITRITES, URINE^99DCT"
name="obs.urinalysis_result_nitrites" required="required" value="2074^STRONG POSITIVE^99DCT"> ++
</label>
<label class="font-normal">
<input id="nitrites_stronger_positive" type="radio" class="urinalysis_result_stronger_positive"
data-concept="9307^PRESENCE OF NITRITES, URINE^99DCT"
name="obs.urinalysis_result_nitrites" required="required" value="2075^STRONGER POSITIVE^99DCT"> +++
</label>
</fieldset>
</div>
<div class="form-group">
<input class="form-control urinalysis_result_date_collected" id="obs_datetime.urinalysis_result_nitrites_date_collected"
name="obs_datetime.urinalysis_result_nitrites_date_collected" type="hidden" required="required"
data-obsdatetimefor="obs.urinalysis_result_nitrites" readonly="readonly">
</div>
<div class="form-group">
<label for="obs.urinalysis_result">Pus Cells:<span class="required">*</span></label>
<fieldset id="obs.urinalysis_result_pus_cells" class="urinalysis_result">
<label class="font-normal">
<input id="pus_cells_nil" class="urinalysis_result_nil" type="radio" data-concept="1984^PRESENCE OF PUS CELLS, URINE^99DCT"
name="obs.urinalysis_result_pus_cells" required="required" value="664^NEGATIVE^99DCT"> Nil
</label>
<label class="font-normal">
<input id="pus_cells_positive" type="radio" class="urinalysis_result_positive"
data-concept="1984^PRESENCE OF PUS CELLS, URINE^99DCT"
name="obs.urinalysis_result_pus_cells" required="required" value="703^POSITIVE^99DCT"> +
</label>
<label class="font-normal">
<input id="pus_cells_strong_positive" type="radio" class="urinalysis_result_strong_positive"
data-concept="1984^PRESENCE OF PUS CELLS, URINE^99DCT"
name="obs.urinalysis_result_pus_cells" required="required" value="2074^STRONG POSITIVE^99DCT"> ++
</label>
<label class="font-normal">
<input id="pus_cells_stronger_positive" type="radio" class="urinalysis_result_stronger_positive"
data-concept="1984^PRESENCE OF PUS CELLS, URINE^99DCT"
name="obs.urinalysis_result_pus_cells" required="required" value="2075^STRONGER POSITIVE^99DCT"> +++
</label>
</fieldset>
</div>
<div class="form-group">
<input class="form-control urinalysis_result_date_collected"
id="obs_datetime.urinalysis_result_date_pus_cells_collected"
name="obs_datetime.urinalysis_result_date_pus_cells_collected" type="hidden" required="required"
data-obsdatetimefor="obs.urinalysis_result_pus_cells" readonly="readonly">
</div>
</div>
<div class="form-group" id="urinalysis_result_date_collected">
<label for="tmp.urinalysis_result_date_collected">Urinalysis Date Collected:
<span class="required">*</span>
</label>
<input class="form-control datepicker" id="tmp.urinalysis_result_date_collected"
name="tmp.urinalysis_result_date_collected" type="text" required="required"
readonly="readonly">
</div>
</div>
</div>
<div class="form-group">
<label class="font-normal" for="tmp.labs_blood_test">
<input type="checkbox" name="tmp.labs" id="tmp.labs_blood_test"> Blood Test
</label>
</div>
<div class="section labs_blood_test">
<div class="form-group">
<label for="blood_test_fbs">Fasting Blood Sugar:</label>
<input class="form-control blood_test labs_blood_test.result" id="blood_test_fbs"
name="blood_test_fbs" type="number"
data-concept="6252^SERUM GLUCOSE, FASTING^99DCT">
</div>
<div class="form-group blood_test_fbs_date_collected">
<label class="font-normal" for="obs_datetime.blood_test_fbs_date_collected">Date Collected [FBS]</label>
<input class="form-control datepicker blood_test_date_collected" id="obs_datetime.blood_test_fbs_date_collected"
name="obs_datetime.blood_test_fbs_date_collected" type="text"
data-obsdatetimefor="blood_test_fbs" readonly="readonly">
</div>
<div class="form-group">
<label for="blood_test_a1c">A1c:</label>
<input class="form-control blood_test labs_blood_test.result" id="blood_test_a1c"
name="blood_test_a1c" type="number"
data-concept="6126^GLYCOSYLATED HEMOGLOBIN^99DCT">
</div>
<div class="form-group blood_test_a1c_date_collected">
<label class="font-normal" for="obs_datetime.blood_test_a1c_date_collected">Date Collected [A1c]</label>
<input class="form-control datepicker blood_test_date_collected" id="obs_datetime.blood_test_a1c_date_collected"
name="obs_datetime.blood_test_a1c_date_collected" type="text"
data-obsdatetimefor="blood_test_a1c" readonly="readonly">
</div>
<div class="form-group">
<label for="blood_test_rbs">Random Blood Sugar:</label>
<input class="form-control blood_test labs_blood_test.result" id="blood_test_rbs"
name="blood_test_rbs" type="number"
data-concept="887^SERUM GLUCOSE^99DCT">
</div>
<div class="form-group blood_test_rbs_date_collected">
<label class="font-normal" for="obs_datetime.blood_test_rbs_date_collected">Date Collected [RBS]</label>
<input class="form-control datepicker blood_test_date_collected" id="obs_datetime.blood_test_rbs_date_collected"
name="obs_datetime.blood_test_rbs_date_collected" type="text"
data-obsdatetimefor="blood_test_rbs" readonly="readonly">
</div>
<label class="alert alert-info" id="dmColumnB">
<b>RBS is >= 7.8</b>
<ul><li>Request patient to come for fasting blood sugar</li></ul>
</label>
<div class="form-group">
<label for="blood_test_creatinine">Creatinine:</label>
<input class="form-control blood_test labs_blood_test.result" id="blood_test_creatinine"
name="blood_test_creatinine" type="number"
placeholder="µmol/L" data-concept="790^SERUM CREATININE^99DCT">
</div>
<div class="form-group blood_test_creatinine_date_collected">
<label class="font-normal" for="obs_datetime.blood_test_creatinine_date_collected">Date Collected [Creatinine]</label>
<input class="form-control datepicker blood_test_date_collected" id="obs_datetime.blood_test_creatinine_date_collected"
name="obs_datetime.blood_test_creatinine_date_collected" type="text"
data-obsdatetimefor="blood_test_creatinine" readonly="readonly">
</div>
<div class="form-group">
<label for="blood_test_haemoglobin">Haemoglobin:</label>
<input class="form-control blood_test labs_blood_test.result" id="blood_test_haemoglobin"
name="blood_test_haemoglobin" type="number"
placeholder="mg/l" data-concept="21^HEMOGLOBIN^99DCT">
</div>
<div class="form-group blood_test_haemoglobin_date_collected">
<label class="font-normal" for="obs_datetime.blood_test_haemoglobin_date_collected">Date Collected [Haemoglobin]</label>
<input class="form-control datepicker blood_test_date_collected" id="obs_datetime.blood_test_haemoglobin_date_collected"
name="obs_datetime.blood_test_haemoglobin_date_collected" type="text"
data-obsdatetimefor="blood_test_haemoglobin" readonly="readonly">
</div>
</div>
<div class="urinePregnancyTestQualitative">
<div class="form-group">
<label class="font-normal" for="tmp.labs_urine_pregnancy_test">
<input type="checkbox" name="tmp.labs" id="tmp.labs_urine_pregnancy_test"> Urine Pregnancy Test
</label>
</div>
<div class="section" id="labs_urine_pregnancy_test">
<div class="form-group">
<label for="obs.urine_pregnancy_test_qualitative">Urine pregnancy test results:<span class="required">*</span></label>
<select class="form-control" id="obs.urine_pregnancy_test_qualitative" required="required"
name="obs.urine_pregnancy_test_qualitative" data-concept="45^URINE PREGNANCY TEST, QUALITATIVE^99DCT">
<option value="">...</option>
<option value="703^POSITIVE^99DCT">Positive</option>
<option value="664^NEGATIVE^99DCT">Negative</option>
<option value="1138^INDETERMINATE^99DCT">Indeterminate</option>
<option value="1118^NOT DONE^99DCT">Test Not Done</option>
</select>
</div>
<div class="form-group urine_pregnancy_test_date_collected">
<label class="font-normal" for="obs_datetime.urine_pregnancy_test_date_collected">Date Collected</label>
<input class="form-control datepicker" id="obs_datetime.urine_pregnancy_test_date_collected"
name="obs_datetime.urine_pregnancy_test_date_collected" type="text"
data-obsdatetimefor="obs.urine_pregnancy_test_qualitative" readonly="readonly">
</div>
<label class="alert alert-info" id="urine_pregnancy_test_reminder">
<b>Pregnancy confirmed</b>
<ul>
<li>Do not dispense</li>
<li>Refer to high risk ANC</li>
</ul>
</label>
</div>
</div>
</div>
<div class="section">
<h3>Complaints</h3>
<div class="form-group">
<label>Does patient report any complaint? <span class="required">*</span></label>
<select class="form-control" id="tmp.reported_complaint" required="required"
name="tmp.reported_complaint">
<option value="">...</option>
<option id="tmp.reported_complaint.yes">Yes</option>
<option id="tmp.reported_complaint.no">No</option>
</select>
<div id="no_reported_complaint" data-concept="8916^CHIEF COMPLAINT, DETAILED^99DCT">
<input id="obs.complaints_shortness_of_breath" type="hidden" name="obs.complaints"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="1107^NONE^99DCT">
</div>
</div>
<div id="reported_complaints" class="form-group concept-set" data-concept="8916^CHIEF COMPLAINT, DETAILED^99DCT">
<label>Does patient have any of the following? <span class="required">*</span></label>
<fieldset id="obs.complaints" name="obs.complaints">
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_shortness_of_breath" type="checkbox" name="obs.complaints"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="5963^SHORTNESS OF BREATH WITH EXERTION^99DCT">
Shortness of breath on activity
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_palpitations" type="checkbox" name="obs.complaints"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="7999^PALPITATIONS^99DCT">
Palpitations (heart racing)
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_recurrent_dizziness" type="checkbox" name="obs.complaints"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="877^DIZZINESS^99DCT">
Recurrent dizziness
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_fainting" type="checkbox" name="obs.complaints"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="7045^FAINTING^99DCT">
Fainting
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_leg_swelling" type="checkbox" name="obs.complaints"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="590^EDEMA, LEGS^99DCT">
Leg swelling
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_loss_of_consciousness" type="checkbox" name="obs.complaints"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="2295^UNCONSCIOUS^99DCT">
Loss of consciousness
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_blurred_vision" type="checkbox" name="obs.complaints"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="8045^BLURRED VISION^99DCT">
Blurring of vision
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_focal_weakness" type="checkbox" name="obs.complaints"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="6005^FOCAL WEAKNESS^99DCT">
Focal weakness
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_foot_complaints" type="checkbox" name="obs.complaints"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="7046^FOOT COMPLAINTS^99DCT">
Foot complaints
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_nausea" type="checkbox" value="5978^NAUSEA^99DCT"
name="obs.complaints" data-concept="5219^CHIEF COMPLAINT^99DCT">
Nausea
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_vomiting" type="checkbox" value="5980^VOMITING^99DCT"
name="obs.complaints" data-concept="5219^CHIEF COMPLAINT^99DCT">
Vomiting
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_abdominal_pain" type="checkbox" value="151^ABDOMINAL PAIN^99DCT"
name="obs.complaints" data-concept="5219^CHIEF COMPLAINT^99DCT">
Abdominal discomfort/diarrhea
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_constipation" type="checkbox" value="996^CONSTIPATION^99DCT"
name="obs.complaints" data-concept="5219^CHIEF COMPLAINT^99DCT">
Persistent constipation
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_chronic_cough" type="checkbox" value="107^COUGH^99DCT"
name="obs.complaints" data-concept="5219^CHIEF COMPLAINT^99DCT">
Recurrent cough
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_mouth_swelling" type="checkbox" value="9308^MOUTH SWELLING^99DCT"
name="obs.complaints" data-concept="5219^CHIEF COMPLAINT^99DCT">
Mouth swelling
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_neck_swelling" type="checkbox" value="8059^NECK SWELLING^99DCT"
name="obs.complaints" data-concept="5219^CHIEF COMPLAINT^99DCT">
Neck swelling
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_headache" type="checkbox" value="620^HEADACHE^99DCT"
name="obs.complaints" data-concept="5219^CHIEF COMPLAINT^99DCT">
Persistent headache
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_excess_hunger" type="checkbox" value="9462^EXCESS HUNGER^99DCT"
name="obs.complaints" data-concept="5219^CHIEF COMPLAINT^99DCT">
Excess Hunger
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_tremors" type="checkbox" value="9461^TREMORS^99DCT"
name="obs.complaints" data-concept="5219^CHIEF COMPLAINT^99DCT">
Tremors
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_sweating" type="checkbox" value="7350^EXCESSIVE SWEAT^99DCT"
name="obs.complaints" data-concept="5219^CHIEF COMPLAINT^99DCT">
Sweating
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_oliguria" type="checkbox" value="6021^OLIGURIA^99DCT"
name="obs.complaints" data-concept="5219^CHIEF COMPLAINT^99DCT">
Reduced urine output
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_oliguria" type="checkbox" value="8935^UNILATERAL WEAKNESS^99DCT"
name="obs.complaints" data-concept="5219^CHIEF COMPLAINT^99DCT">
Weakness in one part of the body
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_nightmares" type="checkbox" value="7754^NIGHTMARES^99DCT"
name="obs.complaints" data-concept="5219^CHIEF COMPLAINT^99DCT">
Nightmares
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_skin_rash" type="checkbox" value="512^RASH^99DCT"
name="obs.complaints" data-concept="5219^CHIEF COMPLAINT^99DCT">
Skin rash
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.complaints_other" type="checkbox" name="obs.complaints"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="5622^OTHER NON-CODED^99DCT">
Other
</label>
</div>
<div class="form-group sub-section" id="complaints_other_value">
<label class="font-normal" for="obs.complaints_other_value">
Specify Other complaint:
</label>
<input class="form-control" id="obs.complaints_other_value" type="text"
name="obs.complaints_other_value" data-concept="1915^FREETEXT GENERAL^99DCT">
</div>
</fieldset>
<label class="alert alert-info stdColumnG">
<b>Patient on enalapril and has recurrent cough</b>
<ul>
<li>Change Enalapril to Losartan and rule out TB</li>
</ul>
</label>
<label class="alert alert-info stdColumnH">
<b>Possible Amlodipine or Nifedipine side effects</b>
<ul>
<li>Stop Nifedipine or Amlodipine</li>
<li>Refer to CO</li>
</ul>
</label>
<label class="alert alert-info stdColumnI">
<b>Possible Metformin side effects</b>
<ul>
<li>Refer to CO OR Reduce Metformin dose</li>
</ul>
</label>
<label class="alert alert-info stdColumnJ">
<b>Possible Hypoglycemia due to glibencalmide</b>
<ul>
<li>Reduce dose OR STOP Glibenclamide</li>
</ul>
</label>
<label class="alert alert-info" id="stdColumnC">
<b>Possible CVS complication</b>
<ul>
<li>Consult on phone 0718980323 and refer</li>
</ul>
</label>
<label class="alert alert-info" id="stdColumnD">
<b>Possible CNS complication</b>
<ul>
<li>Consult on phone 0718980323 and refer</li>
</ul>
</label>
<label class="alert alert-info htnColumnP">
<b>Possible Angioedema side effects due to ACEI/ARB</b>
<ul>
<li>Stop all ACEI/ARB medications</li>
</ul>
</label>
</div>
<div class="section" id="complaints_skin_rash_level" data-concept="9316^LEVEL OF SKIN RASH, DETAILED^99DCT">
<div class="form-group">
<label for="obs.complaints_skin_rash_level">Level of skin rash:<span class="required">*</span></label>
<select class="form-control" id="obs.complaints_skin_rash_level" name="obs.complaints_skin_rash_level"
data-concept="9315^LEVEL OF SKIN RASH^99DCT" required="required">
<option value="">
...
</option>
<option value="1743^MILD^99DCT">
Mild
</option>
<option value="1744^MODERATE^99DCT">
Moderate
</option>
<option value="1745^SEVERE^99DCT">
Severe
</option>
<option value="5622^OTHER NON-CODED^99DCT">
other
</option>
</select>
</div>
<div class="form-group" style="display:none" id="skin_rash_level_other_value">
<label class="font-normal" for="obs.skin_rash_level_other_value">
Specify Other level of skin rash:<span class="required">*</span>
</label>
<input class="form-control" id="obs.skin_rash_level_other_value" type="text" name="obs.skin_rash_level_other_value"
required = "required" data-concept="1915^FREETEXT GENERAL^99DCT">
</div>
<label class="alert alert-info" id="patient_complaints_reminder"> <p>Consider referral to CO</p></label>
</div>
</div>
<div class="section">
<h3>History</h3>
<div class="form-group">
<label for="obs.cigarette_consumption">
Do you smoke cigarettes? <span class="required">*</span>
</label>
<select class="form-control" id="obs.cigarette_consumption" required
name="obs.cigarette_consumption" data-concept="2065^CIGARETTE CONSUMPTION^99DCT">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^No^99DCT">No</option>
<option value="1679^STOPPED^99DCT">Stopped</option>
</select>
</div>
<div class="form-group">
<label for="obs.alcohol_consumption">
Do you sometimes drink alcohol? <span class="required">*</span>
</label>
<select class="form-control" id="obs.alcohol_consumption" required
name="obs.alcohol_consumption" data-concept="1684^ALCOHOL CONSUMPTION^99DCT">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^No^99DCT">No</option>
<option value="1679^STOPPED^99DCT">Stopped</option>
</select>
</div>
<div class="form-group" id="duration_stopped_alcohol">
<label>
How long ago? <span class="required">*</span>
</label>
<div class="sub-section">
<div class="form-group">
<label for="tmp.duration_stopped_alcohol">Duration stopped Alcohol:<span class="required">*</span></label>
<select class="form-control" required name="tmp.duration_stopped_alcohol" id="tmp.duration_stopped_alcohol">
<option value="">...</option>
<option>Weeks</option>
<option>Months</option>
<option>Years</option>
</select>
</div>
<div class="form-group duration_stopped_alcohol" id="duration_stopped_alcohol_weeks">
<label for="obs.duration_stopped_alcohol_weeks">Weeks: <span class="required">*</span></label>
<input class="form-control" type="number" data-concept="1700^STOPPED DRINKING ALCOHOL, WEEKS^99DCT"
placeholder="Duration since stopped alcohol in weeks" id="obs.duration_stopped_alcohol_weeks" required>
</div>
<div class="form-group duration_stopped_alcohol" id="duration_stopped_alcohol_months">
<label for="obs.duration_stopped_alcohol_months">Months: <span class="required">*</span></label>
<input class="form-control" type="number" data-concept="1701^STOPPED DRINKING ALCOHOL, MONTHS^99DCT"
placeholder="Duration since stopped alcohol in months" id="obs.duration_stopped_alcohol_months" required>
</div>
<div class="form-group duration_stopped_alcohol" id="duration_stopped_alcohol_years">
<label for="obs.duration_stopped_alcohol_years">Years: <span class="required">*</span></label>
<input class="form-control" type="number" data-concept="1702^STOPPED DRINKING ALCOHOL, YEARS^99DCT"
placeholder="Duration since stopped alcohol in years" id="obs.duration_stopped_alcohol_years" required>
</div>
</div>
</div>
<div id="alcohol_drinking_details">
<div class="form-group">
<label for="obs.type_of_alcohol">What kind do (did) you usually drink? (tick all that apply)
<span class="required">*</span></label>
<fieldset id="obs.type_of_alcohol">
<div class="form-group">
<label class="font-normal">
<input type="checkbox" name="obs.type_of_alcohol"
data-concept="1685^TYPE OF ALCOHOL CONSUMPTION^99DCT" value="1680^BEER^99DCT">
Beer
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input type="checkbox" name="obs.type_of_alcohol"
data-concept="1685^TYPE OF ALCOHOL CONSUMPTION^99DCT" value="1681^LIQUOR^99DCT">
Spirits / Liquor
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input type="checkbox" name="obs.type_of_alcohol"
data-concept="1685^TYPE OF ALCOHOL CONSUMPTION^99DCT" value="2059^WINE^99DCT">
Wine
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input type="checkbox" name="obs.type_of_alcohol"
data-concept="1685^TYPE OF ALCOHOL CONSUMPTION^99DCT" value="1682^CHANG'AA^99DCT">
Chang'aa
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input type="checkbox" name="obs.type_of_alcohol"
data-concept="1685^TYPE OF ALCOHOL CONSUMPTION^99DCT" value="1683^BUSAA^99DCT">
Busaa
</label>
</div>
</fieldset>
</div>
<div class="form-group">
<label for="obs.alcohol_frequency_last_year">
How often did you have a drink containing alcohol in the last year? <span class="required">*</span>
</label>
<select class="form-control" name="obs.alcohol_frequency_last_year"
id="obs.alcohol_frequency_last_year" required="required" data-concept="5319^AUDIT-3 OVERALL FREQUENCY^99DCT">